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COLLEGE   OF   OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •   LOS  ANGELES,  CALIFORNIA 


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mmSiJi  Of  CALIFORNIA 

CAUFORNIA  COLLEGE  OF  MEDICINE 

LIBRARY 

NOV  1  ;:;  19/0 

IRVINE,  CALIFORNIA  92664 


_ATLAS  OF 
OPERATIVE  GYN/ECOLOGY 


BY 

BARTON  COOKE  HIRST,  M.D. 

Professor  of  Obstetrics,  University  of  Pennsylvania 


16 Jf  PLATES;    ^6  FIGURES 


PHILADELPHIA  &  LONDON 
J.   B.   LIPPINCOTT  COMPANY 


WP  I  n 

t7    D   ^(     ^ 


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Copyright,  1919,  by  J.  B.  Lippinxott  Company 


EUclroty-ped  and  Printed  by  J.  B.  Lippincolt  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


PREFACE 

The  author  has  attempted  the  graphic  method  of  describing  operations 
for  conditions  peculiar  to  women,  by  a  series  of  colored  illustrations  showing 
the  separate  steps  of  each  operative  procedure.  These  illustrations  have 
been  made,  after  repeated  observation  of  the  operations  as  they  were  per- 
formed, by  the  artist,  Mrs.  J.  D.  Z.  Chase.  This  method  enables  even  the 
student  without  previous  operative  experience  to  comprehend  modern 
operative  technic. 

The  text  has  been  subordinated  to  the  illustrations,  saving  the  reader's 
time  and  lightening  the  burden  of  obtaining  a  grasp  of  the  subject. 

The  work  has  been  confined  strictly  to  conditions  peculiar  to  women, 
leaving  the  operations  common  to  both  sexes  to  the  general  surgeon,  who  is 
more  competent  to  deal  with  them. 

The  views  expressed  and  the  operative  technic  advocated  are  based 
on  many  years'  experience  in  dealing  with  all  the  conditions  peculiar  to 
women — an  experience  which  the  author  believes  is  necessarj'  to  a  correct 
judgment  in  selecting  the  operation  best  suited  to  a  woman's  subsequent 

life  history. 

Barton  Cooke  Hirst,  ^I.D. 

Philadelphia.  June,  1919. 


28400 


CONTENTS 

Equipment  and   Preparation  for  Gynecological  Operations 1 

The  Operating  Room 1 

The  Operating  Tables 4 

The  Patient 6 

Instruments 6 

Preparation  for  Vaginal  Operations 10 

Preparation  for  an  Abdominal  Section 13 

Closure  of  Abdominal  Wound 25 

Operative  Technic 25 

A  Rational  Perineorrhaphy 30 

The  After-treatment  of  Perineorrhaphies 31 

Operation     for    Complete    Tear    of    the    Perineum    Through    the 

Sphincter  Ani 46 

After-treatment 46 

Other  Contingencies 47 

Repair   of   Injuries   of  the    Anterior   Vaginal  Wall   Involving   the 

Supports  of  the  Bladder 55 

Laceration  of  Muscle  and  Fascia  of  Urogenital  Trigonum  ....  .56 

Developed  Cystocele 60 

Interposition  Operation 70 

Injuries  of  the  Cervix 85 

Fistula  of  the  Urogenital  Tract 94 

Ureteral  Fistul^e 101 

The  Vaginal  Operations  for  Ureteral  Fistulse 101 

Operative  Treatment  for  Retroversion  of  the  Uterus 102 

Prolapse  and   Inversion  of  the  Uterus 118 

Dilatation  of  the  Cervical  Canal 126 

Instrumental 126 

Anterior  Vaginal  Hysterotomj' 127 

Electrolysis 128 

Operation  for  Enlarging  the  Vaginal  Introitus  in  Cases  of  Vaginismus  135 

Operations  for  Gynatresia 140 

An  Operation  for  Anus  Vestibularis 149 


vi  CONTENTS 

Operations  on  thk  \'ulva 153 

Exsec'tion  of  \'ulvar  Nerves 153 

Dissection  of  the  IiiKiiiiuil  ('anal  for  the  Hciiioval  of  Kilirciiil  'ruiiKirs  of 

tlie  Round  Ligament 153 

Closure  of  the  Inguinal  Canal  for  HcTuia , 153 

Removal  of  the  Vulvovaginal  or  Bartholin's  Gland 154 

Operations  for  Hermaphroditism 154 

Salpingectomy 158 

Operative  Procedure 159 

Ectopic  Gestation 160 

Gonorrhceal   Infection 160 

Drainage 161 

Oophorectomy 169 

Myomectomy 173 

Vaginal   Myomectomy 175 

Hysterectomy 184 

Supravaginal  Amputation  of  the  Uterus  l)y  Abdominal  Section 184 

Panhysterectomy 197 

Extendetl  Panhysterectomy  for  Carcinoma  of  the  Uterus 197 

Pregnancy  Complicating  Cancer  of  the  Uterus 201 

Cuneiform  Hysterectomy  at  the  Fundus  or  the  Cornua 201 

Supravaginal  Extraperitoneal  Hysterectomy  by  the  Vaginal  Route.  .  .  .  207 

Vaginal  Hysterectomy 217 

Cesarean  Section 225 

Conservative  Csesarean  Section 225 

The  Porro  Operation 234 

Su])ravaginal  Amputation  of  tlie  Uterus  with  Extraperitoneal  Fixation 

of  the  Cervical  Stump 234 

Panhysterectomy  with  Csesarean  Section 235 

Extraperitoneal  Caesarean  Section 235 

Pubiotomy 246 

The  After-treatment  of  Abdominal  Section 251 

Surgery  of  the  Mammary  Gland 253 

Surgical  Treatment  of  Mammary  Abscess 253 


ATLAS  OF 
OPERATIVE   GYNAECOLOGY 

EQUIPMENT  AND  PREPARATION  FOR  GYNECOLOGICAL 

OPERATIONS 

The  preparation  for  gynaecological  operations  is  in  many  respects  the 
same  as  the  preparation  for  any  surgical  operation. 

It  is  not  the  purpose  of  the  author  to  repeat  what  can  be  fountl  in  any 
book  on  general  surgery.  There  are,  however,  some  peculiar  requirements 
for  this  special  work  that  deserve  consideration. 

The  Operating  Room. — In  addition  to  a  modern  outfit  for  the  best 
surgical  work,  including  a  good  architectural  plan  and  all  the  necessary 
furniture  and  equipment,  ample  horizontal  light  should  be  provided  for 
vaginal  operations.  This  is  best  secured  by  a  continuous  cut  in  the  roof 
and  wall  for  a  skylight  and  window  combined.  For  emergency  night  work 
I  find  the  lamp  shown  in  Fig.  1  most  convenient.  It  is  cheap,  efficient 
and  compact.  If  the  clinic  must  be  used  for  teaching  students,  the  building 
plans  present  problems  of  great  interest.  In  the  operative  clinic  recently 
completed  for  the  University  Maternity  these  plans  have  been  worked  out, 
I  think,  very  satisfactorily.    (Charts  1  and  2.) 

As  may  be  seen,  there  is  provision  for  the  students  to  change  their 
clothes,  don  their  operating  suits  and  shoes,  and  cleanse  their  hands  and 
arms.  This  student  dressing-room  is  furnished  complete  with  receptacles 
for  sterile  clothing  and  with  containers  to  hold  sterile  gowns  and  caps,  etc. 
A  room  is  provided  for  the  assembling  of  patients  to  be  shown  in  the  clinic 
unansesthetized ;  and,  adjoining  this  room,  is  the  anaesthetizing  room  where 
the  patient  can  be  anaesthetized  in  private  without  being  seen  by  other 
patients  awaiting  operation.  The  anaesthetizing  room  opens  into  the  assem- 
bly room,  which  communicates  directly  with  the  clinic  and  also  communi- 
cates with  the  labor  room  in  which  ordinary  deliveries  are  conducted.  There 
is  a  separate  entrance  for  the  class  and  the  students  between  the  assembly 
room  and  the  clinic  room,  so  that  the  patients  awaiting  operation  or  exhibi- 
tion do  not  see  the  class  and  the  students  as  they  enter  and  prepare  for 
operative  work. 

The  floor  space  of  the  clinic  room,  it  may  be  observed,  is  unusually 
large,  so  that  three  tables  can  be  accommodated  at  once.  There  is  direct 
communication  between  the  operating  room  and  the  dispensary,  so  that 
out-patients  can  be  exhibited  directly  from  the  dispensary  service  if  con- 


2  ATLAS  OF  OPERATHE  GYN.EC'OLOGY 

sidered  desirable.  There  is  no  .special  arrangement  for  i)atliolo{j;ical  work, 
such  as  the  freezing  microtome,  etc.;  as  the  pathological  and  clinical  labora- 
tory work  is  done  in  general  for  all  the  hospital  services.     Provision  is 


Fig.    1. — Lanip  fur  liurizuiital  illutiiinutiun. 


naturallj'  made  for  collecting  specimens,  pus,  etc.,  which  are  conveyed 
directly  to  the  clinical  laboratory  or  to  the  pathological  iaboratorj'  for 
study  and  examination. 


EQUIPIMENT  AND  PREPARATION  3 

The  class  is  divided  into  sections  and  each  man  serves  in  rotation  as 
assistant,  anaesthetist,  and  recorder.  Each  member  of  the  class  has 
an  opportunity  to  assist  a  number  of  times  in  both  pelvic  and  abdominal 
surgerj',  so  that  by  the  end  of  the  final  year  the  man  has  received  as  extensive 
a  practical  training  in  the  surgical  treatment  of  all  affections  peculiar  to 
women  as  it  is  possible  to  give  him  with  the  clinical  service  at  our  command. 

The  records  of  this  service  are  kept  and  handed  in  by  the  student  as 
part  of  his  final  examination,  and  that  part  of  the  class  not  actively  engaged 
in  assisting  takes  notes  of  all  cases  presented  both  for  diagnosis  and  for 
operative  treatment,  these  notes  being  handed  in  at  the  end  of  the  year. 


CHART  1. 


In  the  operative  clinic  not  designed  for  teaching,  the  problem  is  natur- 
ally much  simpler.  In  the  new  private  wing  designed  for  the  Howard 
Hospital,  two  sets  of  operating  rooms  are  to  be  placed  at  either  side  of  the 
sterilizing  room.  At  present,  a  simpler  plan  is  utilized  which  economizes 
space  to  the  utmost  but  at  the  same  time  provides  all  the  essential  compo- 
nent parts  of  an  operative  clinic— namely,  dressing-room,  sterilizing  room, 
operating  room,  anaesthetizing  room,  and  nurses  work-room.  The  anaes- 
thetizing room  is  so  constructed  that  it  can  be  made  a  dark  room  for  cysto- 
scopic  work. 

The  pathological  rooms  and  the  cUnical  laboratory  are  within  easy 
reach  by  an  elevator  in  the  basement  of  the  hospital. 

An  ideal  arrangement,  I  think,  would  be  to  have  a  complete  equipment 
for  each  department  of  medicine;  but  as  the  department  of  obstetrics  and 
diseases  of  women  is  usually  only  one  part  of  a  large  general  hospital,  sep- 
arate pathological  and  clinical  laboratories,  a  special  X-ray  department, 


4 


ATLAS  OF  OPERATIVE  GYN/ECOLOGY 


and  a  department  for  hycb'otherapeutics  would  be  such  an  extravagance 
of  spape  and  equipment,  as  to  make  the  arrangement  impracticable. 

The  modern  ))ractice  of  having  a  different  color  in  the  operating  room 
from  the  customary  glaring  wliite  of  tiles  anil  white  paint  is  an  imjjrovement 
over  the  former  practice;  but  I  have  never  experienced  any  decided  disad- 
vantage from  ()i)erating  in  the  white  operating  room,  and  would  certainly 
not  think  it  wortli  while  to  ccmvert  an  oi)erating  room,  already  constructed 


npcratiiit:  laMi- 


in  this  manner,  into  one  of  a  different  color.  If,  however,  a  new  operating 
room  is  being  constructed,  the  greenish-blue  tint  of  the  new  operating 
rooms  of  the  Brooklyn  Hosj^ital  appeals  to  me  as  the  best  coloring,  instead 
of  the  dark  slate  or  brown  color  seen  in  some  modern  operating  rooms, 
with  an  unpleasant  somber  effect. 

The  Opekating  Tables. — For  all  ordinary  gynaecological  operations, 
I  have  used  for  a  number  of  years  a  simple,  light  table,  reasonable  in  price, 
easily  moved  al)out  on  large  rubber  tired  wheels,  that  serves  as  a  stretcher 
as  well  as  an  operating  table,  saving  two  movings  of  the  patient  from  bed 


BFLOCKIE     AMD     HASTINGS 
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EQUIPMENT  AND  PREPARATION  5 

to  stretcher  and  then  to  operating  table  (Fig.  2).  Three  of  these  tables 
are  in  constant  use  during  the  clinic:  on  one  a  patient  is  being  anaesthetized, 
on  another  an  operation  is  performed,  and  on  the  third  a  wound  is  closed 
bj-  an  assistant. 

This  arrangement  saves  much  of  the  operator's  time.  For  operations 
requiring  deep  and  difficult  work  in  the  pelvis,  such  as  a  Wertheim  operation, 
I  have  one  of  the  complicated  and  expensive  Loewenstein  tables  (Figs.  3 
and  4),  which  are  well  worth  while  for  such  operations  but  are  too  heavy, 
clumsy,  and  luiwieldy  for  routine  use. 


Fig.  3. — Loewenstein  operatin&  table,  most  suitable  for  Wertlieim's  operation. 

An  air  cushion  on  t  he  operating  table  does  much  to  obviate  the  distress- 
ing backache  of  which  the  gynaecological  patient  usually  complains  after 
an  operation. 

The  instrument  tray  and  stand  in  gj-naecological  work  should  be  pro- 
\iiled  with  a  screen  which  is  adjusted  over  the  patient's  chest  in  abdominal 
sections  and  over  the  lower  abdomen  in  plastic  operations  (Fig.  18).  This 
is  much  more  cjuickly  adjusted  than  if  the  screen  were  on  the  operating 
table;  and  being  fixed  to  the  stand  on  which  the  trays  rest  it  is  much  less 
likely  to  get  out  of  order  than  is  the  movable  screen  usually  attached  to  an 
operating  table. 


6  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

The  Patient. — It  is  unnecessary  to  discuss  here  the  usual  preparation 
for  all  surgical  procedure.  Blood  studies;  blood-pressure  estimates;  heart, 
lung,  and  urinary  examinations ;  functional  tests  of  the  kidneys,  and  atten- 
tion to  bowel  evacuations  are  the  same  in  this  special  surgical  work  as  in 
any  other. 

Instruments. — At  a  meeting  of  a  Committee  on  Obstetrics  and  Gynae- 
cology summoned  by  the  Committee  on  National  Defense,  to  prepare  a 
list  of  instruments  essential  for  modern  work  in  the  treatment  of  all  the 


Fig.  4. — -Loewenstein  uperating  table 


Extended   with   iiietid  bar   raised   for   kidney   operations  on  patient  in 
prone  position. 


affections  peculiar  to  women,  those  shown  in  Figs.  6-12  were  selected. 
The  committee  represented  the  eastern  seaboard  of  the  United  States  and 
the  Middle  West.  The  illu.strations  are  interesting  as  showing  the 
collective  judgment  of  different  parts  of  the  country  as  to  what  is  really 
essential  for  the  surgical  treatment  of  conditions  peculiar  to  women.  In 
addition  to  these  essential  instruments,  I  find  myself  constantly  employing 
other  special  implements  without  which  I  should  find  it  inconvenient  to 
do  my  routine  work. 

The  Somers  clamp  is  useful  for  holding  the  uterus  in  suspension  opera- 


EQUIPMENT  AND  PREPARATION  7 

tions  and  in  removal  of  the  appendages  (Fig.  13).  Gelpi's  retractor  is 
invaluable  in  operations  on  the  pelvic  floor  (Fig.  13,  B).  It  is  particularly 
useful  if  there  is  a  paucity  of  assistants.  For  primary  and  intermediate 
operations  on  lacerations  of  the  genital  canal  it  is  extremely  convenient, 
but  is  also  most  useful  in  the  secondary  operation. 

Heineberg's  pan  and  sieve  (Fig.  14)  for  catching  the  endometrium  after 
curettage,  when  it  is  desired  to  preserve  the  scrapings  for  microscopic  study, 


Fig.   5. — Separable  table  for  recumbent  and  rapid  conversion  into  dorsal  gynjecological  position. 

is  one  of  the  nicest  appliances  for  this  purpose  that  I  have  seen,  and  I  use 
it  routinely. 

In  removing  large  fibroid  tumors  a  heavy  volsellum  forceps  is  required 
or  else  its  substitute,  the  corkscrew  (Fig.  15,  B).  The  latter  is  more  conven- 
ient in  tumors  of  the  greatest  size,  as  the  handle  does  not  project  incon- 
veniently far  from  the  tumor;  but  as  a  rule,  I  prefer  the  volsellum  forceps. 

In  isolating  the  round  ligaments  after  opening  the  inguinal  canal, 
blunt  hooks  are  almost  indispensable  (Fig.  13,  D).  I  use  the  kind  devised 
for  the  approximation  of  linear  wounds. 

In  the  Wertheim  operation,  Wertheim  clamps  (Fig.  13,  E)  are  extremely 


ATLAS  OF  OPERATIVE  GYNAECOLOGY 


useful  in  preventing  the  troublesome  hemorrhage  from  the  uterovaginal 
plexuses  of  veins;  and,  in  order  to  protect  the  peritoneal  cavity  as  the  can- 
cerous uterus  is  removed,  the  clami)  devised  by  Sigwart  (Fig.  15,  C)  accord- 


Fla.  6. — a.  HBEinoatatic;  forceps  (Jcmes).  straight,  o-inch,  screw  lock.  b,  Hffimostatic  forceps  (Halstead- 
Army),  straight.  o'2-i"^h,  screw  lock.  c,  Hsemoslatic  forceps  (Kelly-Hopkins),  straight,  flat  shank,  screw  lock. 
d.  Hemostatic  forceps  { Kelly-Pean),  curved,  flat  shank,  6!4-inch,  screw  lock,  e,  Hsemostatic  forceps  (Kocher), 
straight,  S's-inch  screw  lock.    /,  Htemostatic  forceps  (Ochsner),  heavy,  straight,  7'4-inch,  screw  lock. 

ing  to  the  suggestion  of  Bumm  is  most  convenient.  In  this  operation  for 
the  blunt  dissection  of  the  base  of  the  broad  ligament,  as  well  as  in  a 
dissection  of  the  anterior  vaginal  wall,  I  find  GofTe's  dissector  convenient. 


EQUIPMENT  AND  PREP.\RATION  9 

Lion-jawed  forceps  (Fig.  13,  C)  are  useful  in  the  plastic  operations  in  the 
vagina.  In  the  extra-peritoneal  csesarean  section,  T-shaped  hsemostats  are 
essential  for  holding  together  the  layers  of  the  peritoneum  (Fig.  15,  D). 

In  dilating  the  cervix  for  mechanical  dysmenorrhcea  and  sterility  I 
prefer  the  two-  and  four-branched  metranoicter  to  any  other  appliance  (Fig. 


Fig.  7. — a,  Hspniostatic  forceps  tPean),  straight,  S'o-inch.  screw  lock.  b,  Hsemostatic  forceps  vPean), 
curved,  S^-inch.  screw  lock.  c.  Intestinal  forceps  (Doyen),  straight,  9-irieh,  screw  lock.  i/.  Intestinal  forceps 
(Doyen),  curved,  9-inch,  screw  lock. 

16,  A).  I  have  had  a  special  handle  constructed  like  that  of  the  old  Pryor 
clamps  which  facilitates  both  the  insertion  and  the  removal  of  the  instru- 
ment (Figs.  16,  D.  and  17,  B). 

In  addition  to  the  two-branched  dilators  used  for  the  instrumental 
dilatation  of  the  cervix,  I  find  it  essential  to  have  a  four-branched  dilator 


10 


ATLAS  OF  OPERATIVE  GYN^X'OLOGY 


in  addition  and  I  prefer  the  model  named  after  Dr.  Cleveland  of  New  York 
City  (Fig.  17,  C). 

For  the  pregnant  cervix,  J.  C.  Hirst's  modification  of  the  (Jau  dilator 
is  the  most  efficient,  but  occasionally  a  four-branched  dilator  for  this  purpose 
is  convenient.    Of  the  various  models  on  the  market,  1  prefer  that  of  Dewees 

(Fig.  16,:^). 


Fig.  8. —  a.  Sponge  holder,  oval  blades,  8J^-inch,  screw  lock.  6,  Tissue  forceps  ( AUis),  tj-inch,  4x5  teelli, 
screw  lock,  c.  Dressing  forceps,  straight,  10-inch,  with  catch,  screw  lock.  d.  Dressing  forceps  (Bozeuian), 
curved,  10-inch  screw  lock. 

Prep.\ration  for  Vaginal  Operations. — The  first  point  to  be  con- 
sidered is  whether  to  shave  the  patient  before  or  after  anesthetization.  The 
former  saves  time  and  is  cleaner.  It  was  compared  by  the  late  Dr.  Goodell, 
however,  to  the  toilet  of  the  guillotine.  In  a  verj'  nervous  and  api)rehensive 
patient,  therefore,  the  latter  plan  might  be  preferable.  Some  patients  who 
object  to  being  shaved  would  not  mind  a  depilatory.  Frequently  repeated 
enemata  must  be  given  to  empty  the  rectum;  after  the  last,  at  least  half  an 


EQUIPMENT  AND  PREPARATION 


11 


hour  before  the  operation  a  suppository  of  1  grain  extract  of  opium  is 
inserted  to  prevent  defecation  during  the  operation. 

In  cleaning  the  field  of  operation  I  prefer  the  following  plan:  A  nurse 
pours  from  a  pitcher,  over  the  vulva,  inner  thighs,  and  buttocks,  a  stream 
of  lysol  solution,  1  per  cent.,  an  assistant  scrubbing  the  skin  with  pledgets 
of  absorbent  cotton;  after  the  external  cleansing,  the  vulvar  orifice  is  dis- 
tended with  two  fingers  so  that  the  lysol  solution  flows  into  it  and  the  nuicous 


a 


Fio.  9  _„.  Aneurism  needle  (Dechanips),  blunt  point,  right,  b.  Probe,  silver,  strnight.  vvitl.  eye,  t^.j  sizes.  5- 
and  8-inch,  c.  Trocar  and  canula.  small,  medium,  and  large  sizes,  d.  Trocar  disc  and  plain  canula,  two  sizes.  5- 
and  iVinch.     c.  Grooved  director,  plated,  oli-inch. 

membrane  of  the  vagina  is  scrubbed  with  pledgets  of  cotton;  following  this 
the  vagina  is  scrubbed  with  alcohol  and  painted  with  tincture  of  iodine;  a 
pledget  of  cotton  soaked  with  a  1-2000  sul:)limate  solution  is  then  packed 
in  the  \'agina  for  a  coui)le  of  minutes  while  thefassistant  who  does  the  cleans- 
ing changes  his  gloves  and  the  nurses  adjust  the  comliination  sheet  and 
drawers.  This  last  is  a  convenient  device  for  rapidly  covering  the  patient's 
thighs,  legs,  buttocks,  and  public  region.  By  sewing  a  piece  of  rubber  dam 
on  the  inside  of  the  sheet  just  below  the  opening  which  exposes  the  ATilvar 


hi 


ATLAS  OF  OPERATIVE  GYN.^ICOLOGY 


orifice  and  clainpiiifj;  the  sheet  tlius  protected  to  the  buttocks  and  the  middle 
of  the  iierineuni,  the  patient  and  operators  are  protected  from  possible 
fecal  discharges  during  the  operation. 

The  catheterization  of  the  patient  just  before  ana'sthetization  should 
be  done  with  a  short  soft  rubber  catheter,  originally  made  in  Paris,  l)ut 
now  supplied  in  this  country.    The  glass  catheter  frequently  used  for  this 

WW 


Fi«.  10. — a,  Intestinal  needles,  taper  point,  plain  eye.  half  circle,  sizes  1,  2,  'i,  4.  h.  Double-ended  retractor, 
combination  of  Richardson  and  Eastman;  two  sizes,  nested:  blades  ^4x2  inches  and  2  x  2f  2  inches,  c.  Retractor, 
army  type,  two  sizes  nested,  9-  and  10-inch,  d.  Flexible  retractor,  copper,  silver  plated,  e.  Four-prong  sharp 
retractor,  steel.     /.  Self-retaining  abdominal  retractor  (Balfour). 

purpose  should  be  condemned.  The  eye  is  often  rough,  scratching  the 
urethra:  and  the  glass  may  crack  in  boiling  water,  lireaking  off  in  the  bladder 
when  inserted.  This  hapjiened  to  one  of  my  jiatients,  three-cjuarters  of  the 
catheter  remaining  in  the  bladder  a  week  before  it  was  discovered,  as  the 
frightened  nurse  was  afraid  to  report  what  had  happened. 

For   special   cases  some  modification  of   the  technic  is    advisable,   as 
will  be  noted  in  the  description  of  certain  operations. 


EQUIPMENT  AND  PREPARATION 


13 


Preparation  for  an  Abdominal  Section. — In  addition  to  the  usual 
preparation  for  any  major  surgical  procedure,  the  question  of  preparing 
the  skin  of  the  abdomen  must  be  considered.    I  am  opposed  to  the  common 


1 


rs 


y 


_Fiu.  11. — (I.  Uterine  dourhe  (Bozeinan).  b,  I'terine  curette  (Martin),  steel  shank  and  loop,  dull,  size  4. 
h.  Uterine  curette  (Martin),  steel,  double-ended,  blunt  blades,  c.  Uterine  curette  (Sims),  steel  !"ops,  sharp,  sizes 
1,  2,  and  5.  il.  Uterine  tenaculum,  steel,  curved  and  right  angle,  e, Uterine  probe,  silver,  blunt,  with  handle. 
/.  Double  current  female  catheter,   partition  in  center,  sterling  silver,     g.   Uterine  sound  (Simpson). 

practice  of  smearing  tincture  of  iodine  on  the  skin  of  the  abdomen  and  then 
immediately  incising  it,  witli  the  confident  assumption  that  it  is  sufficiently 
sterilized  to  prevent  infection  of  the  wound  or  of  the  peritoneal  cavity.  An 
expert  bacteriologist  would  be  amused  at  this  assumption. 

In  a  series  of   cases  prepared   in   this  manner,    that   I    had    tested, 


u 


ATLAS  OF  OPERATRE  GYN.ECOIXX.Y 


patliogejiic  bacteria  were  found  in  every  one.  The  plan  that  1  usetl  for  a 
number  of  years,  while  troublesome  to  nurses  and  no  doubt  to  the  patient, 
gives,  I  believe,  a  greater  security  not  only  against  wound  infection  Init  against 
peritoneal  infection;  antl  1  feel  that  it  is,  therefore,  worth  while.  The  jnibis 
is  sluiAed,  the  skin  of  the  whole  abtlomen  from  ensiform  to  jiubis  and  from 
flank  to  flank  is  washed  the  evening  before  in  lysol  solution  1  per  cent,  with 


Fig.  12. — a.  Obstetrical  forceps  (Simpson),  lonp,  hnnd-forpcci  blades,  h.  Pelvimeter  (Martin),  with  centi- 
meter scale,  r.  Obstetrical  hook  (Braiinl,  blunt.  </.  \'aginal  retractor  (l^astman),  small,  niedivim.  anii  large  sizes, 
f.  \"aginal  speculum,  weighted  (Auvard).  /.  \'aginal  speculum  (Sims),  double  end,  medium  size,  a.  Rectal 
speculum  (Sims),  bivalve,  wrought  metal. 


pledgets  of  absorbent  cotton  for  ten  minutes;  then  wiped  off  with  alcohol 
and  jirotected  over  night  with  sterile  abdominal  i)ad  and  binder  (Plate  I). 
The  cleansing  is  repeated  the  next  morning  and  finallj'  a  moist  dressing  of 
a  1  per  cent,  formalin  solution  is  applied,  kept  in  place  by  a  binder,  the 
dressing  being  removed  on  the  oj^erating  table  when  everything  is  ready 
to  make  the  abdominal  incision.  When  the  skin  of  the  abdomen  is  exposed 
on  the   operating  table,  the   line  of   incision  is  wii)ed  with  a  5  per  cent. 


EQUIPMENT  AND  PREPARATION 


15 


Fi(^;.  i;i. — A,  The  Soniers'  clamp  for  holding  the  uterus.  B,  Gelpi's  perineal  retraclur.  C,  I.iun-jawfd  I'uncps. 
D,  Blunt  hook  for  picking  up  the  round  ligaments.  E,  Wertheim's  curved  clamp.  F,  Heavy  vulsellum  for  holding 
moderate  sized  fibroid  tumors. 


Fig.   14. — Auvard's  weighted  speculum  and  Heineberg's  pan  and  sieve. 


16 


ATLAS  OF  OPERA'rn'E  (.YN.ECOLOCY 


solution  of  thymol  in  alcohol,  the  pubis  and  thighs  are  co\'ered  with  a  rubber 
sheet  (Plate  II),  the  abdominal  wall  is  incised  (Plate  III),  then  covered 
with  a  piece  of  rubber  dam,  the  protective  perforated  sheet  is  applied  and 
clamped  to  the  skin  of  the  abdomen  (Plate  IV),  the  rubber  dam  is  cut 
through  over  the  abdominal  incision,  the  latter  is  com])leted  through  the 
peritoneum  and  then  the  edges  of  the  peritoneum  are  sewed  to  the  edges 


Fig.    15. — A,  -Author's  scoop  for  interposition  operations,     B.  Corkscrew  for  lioUling  tibroid  tumors. 
C,  Sigwart's  clamp.    D,  T-shaped  hsemostat. 


of  the  rubber  dam  (Plate  V),  thus  giving  perfect  protection  to  operator, 
gloves,  suture  material,  intestines,  and  instruments  from  contamination  by 
the  patient's  skin.  This  system  or  something  like  it  should  appeal  I  think 
to  any  surgeon's  common  sense.  If  he  wear  rubber  gloves  after  a  careful 
hand  cleansing  he  should  be  equally  careful  to  get  the  patient's  skin  out  of 
the  way.  The  mere  clamping  of  towels  in  the  wound  does  not  do  this,  as 
toweling  is  by  no  means  an  impermeable  material.    The  expert  bacteriolo- 


EQl  IPMENT  AND  PREPARATION 


17 


Fig.    Itj. — A.  The    Dewees  four-branched  cervical  dilator.      B.  metal  aseptic  syringe.      <-'.  Dr.  J.  C.   Hirst's    two- 
branched   dilator  for  the  cervix  in  pregnancy. 


FiG.    17. — A.  »SeU-retaining  abdominal  retractur.      U.  Author's  nielranoicter  with  detachable  liandle. 
C.  Cleveland's  four-branched  dilator  for  the  cervix. 


18 


ATLAS  OF  OPERATIVE  GYN/ECOLOGY 


gists  of  two  of  the  leading  catgut  makers  in  tliis  country  have  endorsed 
this  system  and  urged  its  adoption  general]}'.  Moreo\er,  the  results  ob- 
tained confirm  my  confidence  in  it.  In  two  hundred  and  fourteen  successive 
alxlominal  sections,  ol)served  by  one  of  my  internes,  there  were  seven 
infected  wounds,  two  of  which  were  in  cases  of  carcinoma  of  the  bowel  with 
resection,  and  one  was  in  a  nephrectomy  for  tuberculosis  of  the  kidney; 
leaving  only  four  in  which  there  were  infections  that  might  have  been 
avoided,  or  a  percentage  of  1.89.     From  what  I  can  learn  of  the  results 


Fin.   18. — Instriinient  tniy  with  srrcon  attached. 


obtained  l)y  the  use  of  the  iodine  method  I  think  this  percentage  is  de- 
cidedly below  the  average.  An  alternative  simpler  plan  proposed  by 
MacDonald,  niddified,  advocated,  and  used  by  Doctor  Whiting,  and  modified 
by  Edward  Schumann,  of  Philadelphia,  is  to  wash  the  abdomen  the  night 
before  with  soap  and  water  after  shaving  the  symphysis  and  on  the  operating 
table  to  wipe  the  abdominal  skin  for  two  minutes  with  phenoco  2  per  cent., 
acetone  35  per  cent.,  alcohol  63  per  cent.;  and  after  making  the  abdominal 
incision  to  protect  the  skin  and  the  woundwith  thin  sterile  celluloitl.  Doctor 
Schumann  tells  me  he  has  had  200  successive  sections  by  this  plan 
with  no  wound  infections.  A  still  simpler  plan  carried  out  by  Professor 
Edward  Martin  in  the  University  Hospital  of  Philadelphia  is  to  wash  the 


EQl'IPMENT  AND  PREPARATION  19 

abdomen  with  soap  solution,  wipe  the  skin  of  the  aljdonien  with  ether  or 
benzine,  and  then  rub  it  with  dichloramine-T,  5  per  cent. 

In  all  abdominal  tumors  the  rmrse  is  directed  to  use  a  semi-stiff,  long 
silk  catheter.  The  short  female  catheter  may  fail  to  drain  the  bladder,  which 
might  consequently  ])e  cut  in  making  the  abdominal  incision.  The  use  of 
operating  suits,  long-sleeved  gowns,  dry  rubber  gloves,  rubber-soled  white 
shoes,  masks  and  caps  is  uniform  in  all  surgical  clinics. 

Hand  cleansing  is  effected  by  many  different  methods.  ]\Iy  plan  is 
to  wash  with  a  wash  rag  and  grated  hand  soap  after  the  suggestion  of  Royster 
of  North  Carolina ;  then  to  use  tincture  of  green  soap  with  sterile  nail  brush 
and  running  water  for  ten  minutes;  then  with  a  change  of  brushes  to  use 
lJ^sol  and  finally  alcohol,  ending  with  a  rinse  in  sublimate  solution.  The 
hands  are  dried  on  a  sterile  towel.  Two  minor  points  in  aseptic  technic 
deserve  mention,  for  I  often  see  them  neglected.  All  tables  should  be  covered 
with  sterile  mackintosh  or  rublier  and  then  with  sterile  sheets  or  towels 
and  the  rubber  glo\es  should  be  sterilized  in  wallets  laitl  out  flat.  Each 
wallet  should  contain  a  small  pad  of  gauze  thickly  dusted  with  talcum 
powder,  in  order  to  dis])ense  with  the  powder  shaker  which  cannot  be  kept 
bacteria  free.  The  wallet  also  contains  two  light  rubber  bands  to  hold  the 
sleeves  of  the  gown  tight  around  the  wrist  under  the  gauntlets  of  the  gloves. 

In  the  matter  oi  anaesthesia  the  various  plans  in  use  all  have  their 
place  occasionally,  but  I  prefer  nitrous  oxide  gas  followed  by  the  drop  method 
with  ether.  Local  ana'sthesia,  gas  and  oxygen,  gas,  oxygen  and  ether,  and 
chloroform  have  all  been  employed  extensively  in  selected  cases.  The  only 
anaesthesia  I  do  not  like  and  do  not  employ  is  spinal  anaesthesia.  The 
mortality  is  high;  its  chief  advocate  in  Philadelphia  admits  a  mortality 
of  1-500  and  I  have  personal  knowledge  of  at  least  three  cases  of  paralj'sis 
following  its  use. 


PLATE  I. 


^ 


4 


Dressings  an.l  abdominal  binder  in  place  after  preparatory  cleansing  nf  .■didoniinal  surface. 


PLATE   II. 


Dressings  removed,  rubber  sheet  over  thighs. 


PLATE3III. 


I 


/         \ 


>-*> 


\> 


^ 


3V 


^::J[ 


Abdominal  incision  after  a  three-minute  scrub  of  abdomen  with  phenoco  solution. 


PLATE  IV. 


Sterile  rubber  darn  spread  smoothly  over  abdomen.     Abdominal  sheet  adjusted.     Operating  tray  and  screen 
in  place.    The  patient  is  now  protected  irom  head  to  knees. 


PLATE  V. 


Rubber  dam  incised  and  sewed  to  peritoneum.     A  rubber  glove  envelopes  abdomen,  no  skin  appearing  to  con- 
taminate ligatures,  instruments,  operator's  hands  or  patient's  intestines. 


OPERATIVE  TECHNIC  25 

CLOSURE  OF  ABDOMINAL  WOUND  (Plates  VI-IX) 

The  peritoneum  is  sewed  with  plain  unchromecized  number  1  gut  by  a 
running;  mattress  stitch  so  that  peritoneal  surfaces  and  not  edges  are  brought 
together.  This  plan  limits  thelikelihoodofadhesionalong  the  lineof  the  wound. 

If  the  wound  is  a  long  one  a  few  interrupted  stitches  (chromic  gut 
number  1)  unite  the  split  rectus  muscle.  The  fascia  is  united  with  a  running 
stitch  (number  1  chromic  gut),  with  insertions  of  the  needle  somewhat  wide 
of  the  margin  so  as  to  secure  o\erlapping. 

The  fat  is  united  with  a  number  0  stitch  of  gut  in  a  tier  suture  so  as  to 
eliminate  a  dead  space  under  the  skin.    Tension  of  this  stitch  is  avoided. 

After  a  trial  of  many  methods  I  find  an  intracutaneous  or  subcuticular 
stitch  is  best  for  the  skin  and  silkworm  gut  is  the  best  suture  material.  It 
does  not  stretch,  is  clean,  and  secures  a  permanently  narrow,  amost  invisible 
scar.  The  stitch  is  pulled  out  on  the  twelfth  day  by  a  strong  steady  pull 
downward  toward  the  jnibis.  The  wound  is  sealed  with  inch-wide  gauze 
strips  and  collodion.  In  drainage  wounds  silver  foil  is  used  directly  over 
the  wound  above  the  drainage  tract,  made  adherent  bj'  an  overlying  layer 
of  tissue  paper,  moistened  with  alcohol,  and  then  sealed  with  gauze  strips 
and  collodion. 

OPERATIVE  TECHNIC 

Of  the  women  who  consult  physicians  on  account  of  some  pathological 
condition  peculiar  to  their  sex,  more  than  half,  or  over  50  per  cent.,  will 
be  found  to  have  lacerations  of  the  genital  canal.  An  analysis  of  over  eight 
thousand  patients  in  my  i)rivate  case  books  made  some  years  ago,  shows 
this  proportion,  and  it  agrees  with  the  statistics  of  others.  Until  the  best 
method  of  repairing  these  injuries  is  agreed  upon  it  would  seem  useless  to 
proceed  farther  with  a  study  of  the  surgical  treatment  of  diseases  of  women. 
And  yet  there  is  by  no  means  a  unanimity  of  opinion  as  to  the  best  technic 
for  repairing  the  commonest  of  all  these  injuries,  laceration  of  the  pelvic 
floor.  It  must  be  admitted  that  the  ideal  to  be  kept  in  mind  is  a  knowledge 
of  anatomy,  a  knowledge  of  what  happens  to  a  woman  when  she  is  injured 
in  labor,  and  a  restoration  of  each  structure  injured  to  the  condition  it  was 
in  before  the  woman  had  given  birth  to  a  child.  If  this  rule  is  applied  to 
what  is  seen  in  most  surgical  or  gyna'cological  clinics  the  observer  is  amazed 
at  the  ignorance  of  anatomj',  the  disregard  of  the  nature  of  the  original 
injury,  and  the  indifference  to  the  woman's  subsequent  life  history,  .\fter 
seeking  in  vain  in  visits  to  the  clinics  of  this  country'  and  Europe  to  find 
an  ideal  operation  for  the  restoration  of  the  pelvic  floor  and  perineum,  I  was 
obliged  to  devise  an  operation  based  on  these  principles:  As  much  knowledge 
of  the  anatomj'  of  the  region  as  is  required  to  understand  what  hajipcned 
to  it  in  labor,  a  comprehension  of  what  did  occur  in  the  injuries  of  labor, 
and  a  restoration  of  the  parts  to  their  original  condition. 


PI.ATK   VI. 


Suture  of  peritoueum  so  as  to  evert  the  edges  and  bring  peritoneal,  surfaces  in  apposition. 


PLATE  VII. 


Suture  of  fascia. 


PI.ATK    Vlli 


Suture  of  fat  with  two-tier  stitch  and  0  gut. 


PLATE   IX. 


Sub-cuticular  stitch  of  skin. 


30  ATLAS  OF  OPERATI\  E  GYNAECOLOGY 

A  RATIONAL  PERINEORRHAPHY 

'i"he  injuries  inflicted  on  the  pelvic  floor  and  perineum  l)y  the  child's 
head  are  as  follows:  (1)  A  laceration  of  the  levator  ani,  beginning  at  its 
upper  edge  as  a  rifle  and  immediately  beyond  its  attachment  to  the  descend- 
ing ramus  of  the  pubis  running  downward  and  inward  toward  the  lower 
edge  of  the  muscle  but  stopping  short  of  the  median  line;  if  the  muscle  is 
only  partly  torn  through,  the  lower  portion  is  the  part  injured.  (2)  A  median 
separation  of  the  deep  transversus  perina>i  and  a  retraction  laterally  of  the 
two  ends  into  tlieir  sheaths  toward  the  tuber  ischii.  (3)  A  sej^aration  of 
this  muscle  from  its  attachment  near  the  base  of  the  perineal  body.  (4)  A 
triangular  or  rhomboidal  laceration  in  the  middle  line  of  the  pelvic  fascia 
supei'ticial  to  the  le\'ator  antl  deep  transversus  with  the  apex  of  the  triangle 
abo\-e  and  its  base  below  and  a  secondary  triangular  extension  toward  the 
tiji  of  the  posterior  colunui  of  the  vagina.  (5)  A  median  tear  of  the  perineal 
body  se\ering  the  junctions  oi  the  bulbo-ca\"ernosus  muscles  and  of  the 
superficial  transversus  perinaei.    (6)  A  laceration  of  CoUes's  fascia. 

The  illustrations  (Plates  X-XXI)  show  each  step  of  the  repair  of  these 
various  structures  and  their  restoration  to  the  condition  they  were  in  before 
childbirth.  The  incisions  are  best  made  with  a  knife;  the  denudation  with 
scissors.  The  blunt  dissection  of  the  vaginal  wall  i)osteriorly  with  scissors 
can  l)e  done  most  quickly  by  inserting  the  closed  scissors  in  the  midline 
under  the  vaginal  wall  and  spreading  tlie  blades  aiiart  as  the  scissors  are 
pu.shed  upward.  Nunfl)er  1  chromic  gut  is  used  throughout  as  the  suture 
matei'ial.  Extra  hard  number  1  is  used  for  the  skin  of  the  perineimi.  After 
a  trial  of  Michel's  clamps,  silkworm  gut,  linen  thread,  and  heavier  gut, 
this  extra  hard  chromic  gut  number  1  )iro\ed  just  what  I  was  looking  for, 
possessing  sufficient  but  not  too  great  durabihty  and  not  requiring  removal. 

If  the  laceration  of  the  pelvic  floor  has  resulted  in  a  very  extensive 
rectocele  with  redundant  nuicous  membrane,  and  the  condition  has  persisted 
for  some  time,  a  better  denudation  than  that  shown  in  the  first  set  of  illus- 
trations is  an  extensive  triangular  denuilation  such  as  is  made  in  the  old 
Hegar  operation  whicli  remo\(>s  the  redundant  nmcous  membrane;  but  the 
separate  junction  of  the  different  structures  that  have  been  lacerated  is 
accomplished  in  the  manner  described  (folate  XXII).  In  fact  this  operation 
can  be  performed  through  any  one  of  the  three  denudations  commonly  em- 
ployed in  the  pelvic  floor — the  Hegar,  the  modified  Emmett,  or  the 
transverse  dissection  between  vagina  and  rectum. 

It  is  a  reproach  to  medicine  that  such  enormous  numbers  of  women 
require  the  secondary  repair  of  the  pelvic  floor.  This  regretable  fact  is 
due  mainly  to  the  unsuccessful  practice  of  imifietliate  repair,  directly  after 
child-birth,  when  absence  of  a  special  table,  insufficient  light,  lack  of  assist- 
ance, a  profuse  bloody  discharge,  bruising  and  distortion  of  the  tissues 


RATIONAL  PERINEORRHAPHY  31 

usually  prevent  an  accurate  diagnosis  and  often  make  an  accurate  and  suc- 
cessful repair  impracticable.  The  patients  I  frequently  examine  (repaired 
immediately  by  professed  specialists  in  obstetrics)  often  present  such  a 
sorry  spectacle  as  to  convince  anyone  of  the  futility  of  such  work.  ^ly 
practice  for  more  than  fifteen  years  in  private,  ho.spital,  and  dispensary 
patients  has  been  to  wait  at  least  five  days  before  attempting  a  repair  of 
the  genital  canal.  Even  if  it  were  practicable  to  repair  the  pelvic  floor 
immediately  with  uniform  success  (which  it  is  notj  ample  clinical  experience 
in  many  clinics  has  demonstrated  that  the  cervix  and  anterior  wall  cannot 
safely  be  repaired  immediately.  There  seems  to  be  little  sense  in  attempting 
an  imperfect  repair  of  one  part  of  the  genital  tract  and  then  subjecting  the 
patient  to  a  secondary  operation  for  the  repair  of  the  rest  of  it.  Objections 
to  this  plan  of  intermediate  operations  are  that  the  patient  resents  an  etheri- 
zation some  days  after  delivery;  that  the  fees  are  usually  too  small  to  com- 
pensate the  physician  for  the  extra  trouble;  that  the  physician  often  lacks 
the  operative  training  necessary  for  an  intermediate  operation ;  that  infection 
is  promoted  by  leaving  the  perineal  wound  imsutured;  and  that  ansestheti- 
zation  and  operation  may  interfere  with  milk  secretion.  These  objections 
have  not  proved  valid  in  my  experience. 

Another  objection  is  raised  that  deserves  little  attention.  It  has  been 
stated  that  intermediate  operations  cannot  be  done  with  sucee.ss.  This 
statement  is  made  only  by  that  type  of  specialist  too  common  in  America — 
the  obstetrician  with  scanty  experience  in  surgery  and  poor  surgical  training. 
In  the  many  hundreds  of  cases  subjected  to  these  operations  by  my.self  and 
my  assistants  in  tlie  last  fifteen  years  the  success  has  been  as  uniform  as 
in  secondary  operations;  and  we  have  been  spared  the  humiUation,  to  which 
the  advocates  of  immediate  operation  are  liable,  of  hearing  that  their 
patients  (who  have  been  assured  they  were  repaired  immediateh')  have  been 
obliged  to  be  operated  on  subseciuently  because  the  original  work  was  so 
poorly  done.  There  is  no  additional  danger  of  infection  by  waiting,  other- 
wise every  wound  in  the  genital  canal  should  be  repaired — a  procedure  that 
no  one  advocates  or  attempts.  Besides,  ample  experience  bears  out  this 
statement.  Indeed,  the  way  the  perineum  is  usually  repaired  primarily, 
leaving  ununited  wounds  above  the  perineum  proper,  makes  the  patient 
more  liable  to  infection  than  if  no  sutures  had  been  inserted. 

The  After-treatmext  of  Perineorrhaphies.  —  The  vagina  is 
sponged  out  with  dry  pledgets  of  gauze  when  the  operation  is  finished. 
Irrigation  of  the  wound  during  and  after  the  operation  is  avoided.  I  saw 
the  former  practice  carried  out  in  Berlin  thirty  years  ago,  but  it  has  since 
been  given  up.  Some  operators  in  this  country  still  persist  in  its  use.  The 
vagina  is  packed  lightly  with  sterile  gauze  that  remains  for  twenty-four 
hours;  the  patient   is  encouraged  to  pass  water   naturally,   if   she   can; 


32 


ATLAS  OF  OPERATIVE  (;YN\ECOLO(iY 


otherwise  she  is  catheterized  every  eight  hours.  After  the  fifth  ihiy  a  sterile 
water  tlouche  is  o;i\("n  every  other  (hiy.  The  woman  remains  in  bed  twelve 
to  fourteen  days. 


F:a.     19.- 


-Patient  arranged  for  plastic  operation  with  .\uvard's  weighted  speculum  and  Heineberg's  funnel 
and  sieve  in  place  and  operating  tray  ovi-r  the  symphysis. 


PLATE  X. 


A  ratiuiial  ptrriiifMiTluipliS".      (iaping  vulvar  oritit-e  with  urellinx'ele  and  cystocele. 


PLATE    XI. 


Incision  tlirougli  mucous  membrane  to  expose  underlying  fascia  and  muscles. 


PLATE   XII. 


Flaps  of  mucous  membrane  to  be  excised  along  dotted  lines. 


PLATK  XIII 


Botli  layers  of  triangular  ligament  cut  through  to  expose  levator  ani  muscle. 


PLATE  XIV. 


Levators  sutured  and  incision  made  to  expose  tlie  deep  transversiis 


Levator  ani  anj  subjacent  fascia  closed;  inferior  layer  of  triangular  ligament  incised  to  expose  the  deep  trans- 
versus  pcrinsei  which  is  sewed  in  such  a  manner  as  to  unite  its  ends  and  restore  its  triangular  shape. 


PLATE  XVI. 


Gap  in  perineal  center  and  pelvic  fascia,  through  which  rectocele  protrudes,  closed  by  tier  stitch. 


PLATE   XVII. 


Mucous  membrane  and  subjacent  connective.tissue  of  sulci  closed  by  two-tier  stitch. 


PLATE   XVIII. 


Stitch  to  restore  the'  lower  tip  of  posterior  column  of  vagina. 


PI-ATI-:   XIX. 


Perineal  center  or  body  and  Colles's  fascia  united  by  interrupted  stitches. 


PLA1E   XX. 


Skin  sutures;  Xo.  1.  over-cbromicized  gut. 


PLATE  XXI. 


Operation  completed. 


PLATE   XXI 


Incision  for  Hegar's  denudation  of  perineum. 


46  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

OPERATION  FOR  COMPLETE  TEAR  OF  THE  PERINEUM 
THROUGH  THE  SPHINCTER  ANI 

The  jM-eparatory  treatment  for  this  operation  (Plate  XXIII)  should 
he^in  forty-eight  hours  i^eforehand  by  purgation  and  a  thorough  evacuation 
of  the  rectum.  I  prefer  Rochclle  salt,  2  drachms  the  first  night,  and  Epsom 
salt,  4  drachms  the  secoiul  night,  followed  on  the  morning  of  the  operation 
by  repeated  irrigations  of  the  rectmn  with  soap  suds  and  sterile  water 
till  it  is  thoroughly  em])tied,  and  then  by  an  opium  suppository. 

The  first  stej)  in  the  operation  is  stretching  the  sphincter,  which  is  not 
done  in  the  usual  manner,  but  by  catching  the  retracted  ends  between  the 
thumb  and  forefinger  and  pulling  what  is  really  a  ribbon  and  not  a  ring 
muscle  in  the  direction  of  its  long  fibres  (Plate  XXIV).  Then  follow  the 
steps  of  the  operation  as  shown  in  Plates  XXV-XXIX.  The  most  important 
detail  of  the  operation  is  hooking  the  ends  of  the  muscle  into  plain  view  by 
pulling  them  out  of  the  pits  into  which  they  have  retracted  as  shown  in 
Plate  XXVI. 

An  interesting  question  is  the  kind  of  suture  material  to  employ  in 
joining  the  ends  of  the  muscle.  After  a  trial  of  catgut  and  linen  thread  I 
find  it  necessary  to  use  silkworm  gut  as  the  only  reliable  material  to  hold 
the  ends  of  the  muscle  firmly  together  without  danger  of  premature  absorp- 
tion, stretching,  or  infection.  The  rest  of  the  suturing  is  done  with  number  1 
chromic  gut.  The  sutures  in  the  sphincter  may  be  inserted  in  such  a  way 
as  to  pull  down  a  flap  of  rectal  wall  under  the  junction  of  the  sphincter, 
to  protect  it  from  fecal  contamination  (Noble). 

Usually  in  a  complete  tear  the  perineal  body  alone  is  involved  in  the 
laceration.  The  other  muscular  and  fibrous  structures  of  the  pelvic  floor 
are  spared.  But,  should  they  be  involved,  their  repair  is  effected  by  the 
technic  already  described  for  perineorrhaphies. 

After-treatment. — The  after-treatment  of  a  complete  tear  operation 
is  as  important  as  the  operation  itself.  I  have  tried  opening  the  bowels  at 
all  sorts  of  times,  even  up  to  the  sixteenth  day  as  proposed  by  Leopold ;  but 
of  late  years  have  adopted  one  of  two  plans  dependent  upon  the  kind  of 
nursing  the  patient  could  afford.  If  a  special  nurse  is  in  attendance  I  prefer 
the  evacuation  of  the  bowels  daily  or  twice  daily  from  the  first  day.  A 
semi-liquid  stool  is  best  secured  by  Carlsbad  water  or  by  Bedford  spring 
water  and  Sprudel  salt,  which  the  patient  can  take  for  a  couple  of  weeks 
or  more  without  irritating  the  stomach  or  intestines.  One  glass  of  the  water 
with  a  teaspoonful  of  the  salt  twice  a  day  is  the  average  dosage. 

The  line  of  sutures  in  the  perineum  must  be  thoroughly  irrigated  after 
each  bowel  movement  and  urination,  and  then  dusted  with  formic  bismuth 
iodide  powder.  If  the  patient  is  in  a  ward  and  cannot  secure  the  undivided 
attention  of  a  nurse,  the  bowels  are  opened  on  the  fifth  day  with  calomel, 


OPERATION  FOR  COMPLETE  TEAR  OF  PERINEUM  47 

castor  oil,  and  an  oil  enema  given  carefully  through  a  rubber  catheter. 
Afterwards  the  bowels  are  kept  semi-liquid  as  in  the  first  technic.  The  two 
or  three  silkworm  gut  sutures  in  the  sphincter  are  removed  in  twelve  to 
fourteen  days. 

Other  Contingencies. — If  the  laceration  runs  far  up  the  recto- 
vaginal septum  I  find  the  sphincter  is  better  brought  together  and  held  in 
position  by  knotting  the  silkworm  gut  sutures  in  the  rectum.  Their  removal 
is  troublesome.  The  knee-chest  posture,  a  narrow  rectal  speculum  and  an 
electric  head  light  may  be  required;  but  the  extra  trouble,  I  think,  is  well 
worth  while. 

In  the  rather  common  cases  in  which  a  sphincter  repair  has  been 
attempted  with  an  imperfect  result  and  the  operator  has  to  do  someone 
else's  work  over  again,  there  is  often  a  bridge  of  tissue  healed  over  the 
perineum  and  above  the  anus,  but  no  union  of  the  sphincter  muscle;  and 
there  is  often  a  recto-vaginal  fistula  just  within  the  posterior  commissure 
of  the  vulva.  The  best  plan  in  such  cases  is  to  put  one  blade  of  a  scissors 
into  the  hole  communicating  with  the  rectum  and  with  the  other  on  the 
exterior  of  the  perineum  to  cut  the  perineum  open  from  top  to  bottom  and 
then^'to  do  the  operation  again  as  though  the  injury  were  a  fresh  one. 

In  the  very  rare  cases  of  central  perforation  of  the  perineum,  the  peri- 
neum is  cut  upward  from  the  perforation  to  the  posterior  commissure  of 
the  vulva  and  then  the  pelvic  floor  and  perineum  are  repaired  in  the  manner 
already  described.  If  the  perforation  takes  the  shape  of  an  oblique  slit 
running  diagonally  across  the  perineum,  tier  sutures  of  catgut  should  be 
employed.  After  a  repair  of  the  sphincter  the  patient  should  be  cautioned 
to  keep  the  bowel  movements  soft  for  .several  months. 


PLATE   XXI  il. 


Complete  tear  through  sphincter  ani. 


J^LATE   XXI\'. 


Stretching  sphincter  which  when  torn  through  is  a  ribbon  and  not  a  ring  muscle. 


PT.ATK   \\V. 


InciMon  for  Hup  splilliiiii  cli'iiii.lal  inTi 


PLATE  XXVI. 


Flap  splitting  denudation  completed.     Rectovaginal  septum  sutured.     Ends  of  sphincter  caught  by  sharp 
hooks  and  brought  out  of  their  pits  into  plain  view. 


PLATE  XXVn. 


Sutures  of  ailkworm  gut  inserted  through  sphincter  muscle  and  its  sheath. 


PLATE  XXVIII. 


Sphincter  joined  and  perineal  body  sutured. 


PLATE  XXIX. 


Skin  sutures  tied. 


REPAIR  OF  INJURIES  OF  ANTERIOR  VAGINAL  W.\LL  55 

REPAIR  OF  INJURIES   OF  THE   ANTERIOR  VAGINAL  WALL 
INVOLVING  THE  SUPPORTS  OF  THE  BLADDER 

Before  attempting  the  repair  of  these  injuries  it  is  necessary,  as  in  the 
case  of  injuries  to  the  pelvic  floor  and  perineum,  to  understand  the  anatomy 
of  the  region,  to  know  what  happens  to  a  woman  when  she  is  injured  in 
labor,  and  to  devise  an  efficient  operative  technic  which  will  either  restore 
the  injured  parts  to  their  original  condition  or  will  so  rearrange  the  anatomi- 
cal elements  as  to  give  the  anterior  wall  and  bladder  the  support  which  has 
been  impaired  by  childbirth. 

The  injuries  to  which  the  anterior  vaginal  wall  is  subject  in  labor  are 
as  follows:  (1)  A  laceration  in  one  or  both  anterior  sulci  of  the  muscle  and 
fascia  of  the  urogenital  trigonum — a  musculo-fibrous  band  about  an  inch 
wide,  stretching  across  the  anterior  portion  of  the  pelvic  outlet  from  one 
ischio-pubic  junction  to  the  other  one,  the  only  support  of  the  lower  third 
of  the  anterior  vaginal  wall,  and  the  only  muscle  in  this  region  the  fibres  of 
which  are  directly  inserted  into  the  vaginal  wall  (Waldeyer).  This  muscle 
lies  between  the  two  layers  of  the  triangular  ligament:  it  is  continuous  with 
the  deep  transversus  perinsei  and  is  the  homologue  of  the  compressor 
urethra?  in  the  male.  (2)  A  diastasis  of  the  plate  of  pelvic  fascia  between 
the  cervix,  the  anterior  vaginal  wall,  and  the  bladder  by  the  lateral  pressure 
of  the  child's  head.  (3)  An  elongation  of  the  longitudinal  connective  tissue 
fibres  between  the  cervix  and  the  bladder.  (4)  An  injury  in  the  shape  of 
laceration  or  over-stretching  of  the  cardinal  ligaments  of  the  uterus— those 
strong  fibrous  bands  in  the  bases  of  the  broad  ligaments,  extending  outward 
and  backward  to  the  pelvic  wall;  the  strongest  supports  possessed  by  the 
uterus,  injury  to  which  deprives  the  upper  third  of  the  anterior  wall  and  the 
anterior  vault  of  the  vagina  of  the  support  derived  from  its  connection  with 
the  cervix.  With  a  weakening  of  this  support,  the  cervix  is  allowed  to  drop 
downward  and  forward  along  the  vaginal  canal,  and  to  pull  the  anterior 
vaginal  vault,  the  upper  third  of  the  anterior  vaginal  wall,  and  the  base  of 
the  bladder  with  it. 

The  commonest  cause  of  this  last  injury  is  the  premature  application 
of  the  forceps  before  full  dilatation  of  the  cervix  and  before  the  child's 
head  is  well  descended  into  the  pelvic  canal.  Another  common  cause  is 
puUing  upon  a  conical  rubber  bag  like  the  Voorhees,  inserted  in  an  undilated 
cervical  canal.  A  contributing  cause  is  an  overfilled  bladder  which  has  not 
been  emptied  as  it  should  be  before  the  application  of  forceps.  The  most 
frequent  of  the  injuries  to  the  anterior  wall  is  the  laceration  of  the  muscle 
and  fascia  of  the  urogenital  trigonum.  It  stands  to  the  injuries  of  the  pelvic 
floor  in  about  the  proportion  of  eight  to  ten— that  is,  if  fifty  per  cent,  of 
women  have  distinct  damage  to  the  pelvic  floor  in  labor,  forty  per  cent, 
will  show  lacerations  of  the  anterior  sulci,  involving  the  muscle  and  fascia. 


56  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

Laceration  of  Muscle  and  Fascia  of  Urogenital  Trigonum. — 
The  only  one  of  these  injuries  which  can  be  corrected  shortly  after  labor 
is  the  laceration  of  the  muscle  and  fascia  of  the  urogenital  trigonum.  This 
injury  can  be  corrected  at  the  same  time  that  the  i)el\ic  floor  and  cervix 
are  repaired;  that  is  to  say,  from  five  to  seven  days  after  ialxir  in  the  inter- 
mediate operation  (Plates  XXX-XXXII).  The  injury  to  the  anterior 
wall  is  sometimes  a  frank  one;  the  laceration  extends  through  the  nuicous 
membrane  and  the  triangular  ligament  underlying  it,  exposing  the  muscular 
fibres,  which  are  torn  across ;  but  often  the  injury  is  submucous  and  concealed 
so  that  to  expose  the  injured  muscle  and  fascia  it  is  necessary  to  incise  the 
superficial  fascia  or  inferior  layer  of  the  triangular  ligament  overlying  it  as 
is  illustrated  in  Plate  XXX. 

The  muscle  being  exposed,  the  fibres  can  be  brought  together  with  a 
continuous  two-tier  number  1  catgut  suture,  the  superficial  layer  of  which 
closes  the  wound  in  the  superficial  fascia.  The  denuded  surface,  if  a  deiui- 
dation  has  been  necessary,  is  then  repaired;  or,  if  the  nuicous  membrane 
is  torn,  it  and  the  subjacent  tissues  are  united  by  two-tier  stitches. 

This  operation  can  also  be  done  as  a  secondary  one  and  is  very  com- 
monly required  in  moderate  injuries  of  the  genital  canal.  The  existence 
of  the  injury  is  determined  by  light  pressure  upward  and  outward  with  the 
forefinger  inserted  up  to  the  middle  joint;  the  left  hand  being  used  for  the 
left  side  of  the  woman's  pelvis,  the  right  hand  for  the  right  side  of  the  pelvis. 
If  the  fascia  and  nuiscle  have  been  torn,  the  palmar  surface  of  the  finger 
comes  in  direct  contact  with  the  edge  of  the  pubic  bone,  nothing  intervening 
except  the  mucous  membrane  of  the  vagina.  If,  on  the  contrary,  this 
structure  has  not  been  injured  there  is  a  distinct  resistence  felt  to  the  pres- 
sure upward  and  outward,  and  a  cushion  of  musculo-fibrous  tissue  is  dis- 
tinctly appreciated  between  the  examining  finger  and  the  pubic  bone. 

The  correction  of  this  injury  checks  a  process  which,  if  not  corrected, 
woiild  end  eventually  in  the  formation  of  a  cystocele.  As  the  structure 
injured  is  the  only  support  possessed  by  the  lower  third  of  the  anterior 
vaginal  wall  and  the  corresponding  section  of  bladder  and  urethra,  these 
latter  two  structures,  unsupported,  sag  downward  and  outwartl;  and,  in 
course  of  time,  drag  the  structures  above  them  lower  antl  lower  until  event- 
ually a  well-marked  cystocele  develops. 

It  is  all  the  more  certain  to  do  this  if  there  is  diastasis  of  the  pelvic 
fascia  and  elongation  of  its  longitudinal  fibres,  as  well  as  injury  to  the 
cardinal  muscles  or  ligaments  of  the  uterus;  but  I  believe  that,  even  without 
these  injuries,  the  damage  to  the  muscle  and  fascia  of  the  urogenital  trigonum 
alone  is  sufficient  in  time  to  develop  a  cystocele;  and  I  am  firmly  con\inced, 
after  some  ten  years'  experience  with  the  repair  of  this  damage,  that  its 
earl.y  recognition  and  repair  will  often  jire\ent  the  formation  of  a  cystocele 


PLATE  XXX. 


Expoaure  of  compressor  urethrse  by  incision  through  interior  layer  of  triangular  ligament. 


pr.\rr:  x.wi. 


Exposed  muscle  sutured. 


PLATE   XXXII. 


Sub-mucous  connective  tissue  united  over  muscle  and  fascia.      Mucous  membrane  united. 


60  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

later  in  the  woman's  life.  A  longer  time,  however,  than  has  so  far  elapsed 
is  necessary  to  a  clear  demonstration  of  this  assertion. 

Developed  Cystocele. — In  dealing  with  a  cystocele  already  developed 
the  problem  is  a  more  complicated  one.  The  restoration  of  the  muscle  and 
fascia  of  the  urogenital  trigonum  alone  is  not  sufficient  to  effect  a  cure.  A 
more  extensive  operation  is  required. 

The  choice  of  operation  depends  in  great  iiart  upon  the  woman's  age 
and  her  future  prospects  of  child-bearing.  If  she  is  approaching  middle 
age  or  has  already  reached  the  menopause  there  is  no  question  that  the 
interposition  operation,  introduced  into  this  country  by  Watkins,  of  Chicago, 
is  the  most  efficient  means  of  curing  a  cystocele  (Plates  XXXIII-XLI). 


PLATE  XXXIII. 


Incision  and  dissection  for  interposition  of  uterus. 


IM.ATK  XXXIV. 


Cutting  atL-ru\  faiea,!  hgaineut. 


PLATE   XXXV, 


Opening  peritoneal  cavity. 


ri-ATK    XXXVI, 


Extracting  corpus  uteri  with  scoop. 


t'LATE   XXXVII. 


Pulling  out  the  fundus. 


PLATE   XXXVIII. 


.jf" 


:r-i:fy^^, 


A. 


Stitching  the  fundus  of  the  corpus  uteri  to  fasi*i;il  tdt^en  under  vagioal  mucous  membrane. 


PI.ATK   XXXIX. 


Cutting  iit^  supertluous  vaginal  tlaps. 


?I,\TK    XT.. 


I'niting  vaginal  incision  to  cervix, 


PLATE  XLI. 


\'agiiial  wound  closed. 


70  ATLAS  OF  OPERATIVE  GYN^X  OLOGY 

Interposition  Operation. — Wat  kins  gives  Diihrssen  credit  for  priority 
in  the  interposition  operation,  which  Watkins  prefers  to  call  a  transposition 
operation.  \Vatkins  indejjendently  developed  this  operation  in  1898. 
Wertheini  developed  the  same  procedure  a  year  later,  with  the  difference 
that  he  left  a  portion  of  the  uterine  surface  exposed  in  the  vagina.  The 
next  important  modification  in  the  operation  was  by  Schauta  who  sewed 
the  peritoneum,  where  it  was  separated  from  the  back  wall  of  the  bladder, 
to  the  posterior  j)eritoneal  surface  of  the  uterus  at  the  level  of  the  internal  os. 
In  making  the  vaginal  incision  and  separating  the  vagina  from  the  bladder, 
Watkins  and  most  operators  exploy  a  blunt  dissection  by  passing  scissors 
under  the  vaginal  wall  in  the  plane  of  separation  between  the  vagina  and 
the  fascia  underlying  the  bladder.  But  I  teach  my  students  to  make  a 
formal  dissection,  feeling  that  there  is  less  risk,  by  this  method,  of  injuring 
the  bladder  in  the  hands  of  a  beginner;  although  personally  I  use  Watkins's 
method  of  dissection,  which  results  in  less  bleeding  and  is  quicker. 

Separation  of  bladder  and  vagina  can  be  further  extended  by  a  piece  of 
gauze  over  one  finger  which  carries  out  an  extension  of  the  dissection  begun 
with  the  scissors.  In  separating  the  uterus  from  the  bladder,  I  prefer  the 
discission  of  the  utero-vesical  ligament  with  scissors,  rather  than  by  the 
blunt  dissection  with  the  blunt  scissors  point  as  Watkins  recommends. 
I  believe  the  latter,  except  in  the  hands  of  the  most  experienced  operators, 
endangers  the  bladder  too  much.  After  the  utero-vesical  ligament  has  been 
cut,  a  retractor  must  be  inserted  between  the  bladder  and  the  uterus.  In 
this  way,  the  peritoneal  fold  between  the  bladder  and  the  uterus  is 
plainly  exposed  and  can  be  safely  cut  through  without  danger  of  cutting 
the  bladder  wall. 

For  the  delivery  of  the  uterus  I  have  had  made  a  scoop  which  I  find  very 
convenient,  although  occasionally  I  am  obliged  to  pull  the  uterus  out  with 
a  tenaculum  forceps — two  being  used,  one  above  the  other,  and  several  grips 
perhaps  being  taken  of  the  anterior  surface  of  the  uterus  by  a  sort  of  hand- 
over-hand procedure  before  the  fundus  can  be  readily  extracted.  If  the 
cystocele  is  extreme  in  degree  and  associated  with  considerable  prolapse 
of  the  uterus,  I  employ  Schauta's  modification  of  the  suture  of  the  peri- 
toneum over  the  back  wall  of  the  bladder  to  the  posterior  peritoneal  surface 
of  the  uterus  at  the  level  of  the  internal  os.  As  the  uterus  is  pushed  up  by 
the  closure  of  the  vaginal  wall  under  it,  and  as  the  cervix  is  pu.shed  backward 
and  upward,  this  attachment  of  the  uterus  to  the  peritoneal  reduplication, 
as  it  leaves  the  bladder,  lifts  the  latter  to  a  higher  level  in  the  pelvis  than 
is  done  by  the  Watkins  or  the  Wertheim  technic.  I  find  it,  therefore,  of 
distinct  advantage. 

It  is  not  infrequently  necessary  to  reduce  the  size  of  the  uterus  (Plate 
XLII).    This  can  readily  be  done  by  an  excision  of  a  wedge-shaped  piece 


REPAIR  OF  INJURIES  OF  ANTERIOR  VAGINAL  WALL  71 

from  the  anterior  uterine  wall;  and  occasionally  it  is  an  advantage  to  unite 
with  this  procedure  an  excision  of  the  uterine  mucous  membrane.  The 
wound  in  the  uterus  is  closed  by  interrupted  sutures  through  the  myome- 
trium and  I  think  with  advantage  also  by  a  running  stitch  on  the  surface 
of  the  uterine  wound. 

I  have  often  found  it  of  advantage  not  to  deliver  the  uterus  completely; 
or  rather,  after  having  delivered  it,  to  push  it  part  way  back  and  then  to 
fasten  the  fundus  uteri  well  forward  directly  under  the  urethra  to  the 
fascial  pillars  which  diverge  at  this  point,  and  not  to  the  vaginal  mucous 
membrane.  I  think  by  this  plan  there  is  less  danger  of  a  protrusion  of 
the  fundus  uteri  e\-entually — an  experience  which  Watkins  and  other 
operators  have  had.  This  procedure  also  makes  it  easier  to  close  the 
vaginal  flap  over  the  uterine  surface. 

If,  however,  there  is  great  relaxation  of  the  anterior  vaginal  wall,  and 
for  a  more  extensive  cystocele  than  common,  this  procedure  does  not  do 
so  well.  In  such  cases  I  follow  out  the  Watkins  technic,  with  Schauta's 
modification  (Plates  XLIII-XL\M. 

It  appears  from  the  illustrations  (Plates  XXXIII-XLI)  of  Watkins's 
operation  that  he  depends  on  a  single  stitch  of  catgut  to  fasten  the  fundus 
uteri  to  the  vaginal  wall  close  under  the  urethra.  I  find  it  better  to  insert 
each  stitch  through  both  the  vaginal  wall  and  the  uterine  body  from  the 
fundus  downward  toward  the  cervix,  using  interrupted  sutures  and  not 
suturing  the  raw  surface  of  the  cervix  below  the  peritoneal  co^•ering  of  the 
uterus.  Watkins's  proposition — to  close  the  transverse  incision  at  the  cervix 
longitudinally  in  order  to  lengthen  the  anterior  wall  and  to  replace  the 
cervix  farther  backward — is  an  excellent  one  in  occasional  cases. 

The  advice  to  excise  the  redundant  mucous  membrane  over  a  urethro- 
cele is  also  wise. 

Dependent  upon  the  degree  of  prolapse  associated  with  the  cystocele, 
the  vagina  should  be  sufficiently  narrowed  by  a  proper  pelvic  floor  support, 
the  denudation  for  which,  in  this  case,  should  be  the  triangular  one  of  the  old 
Hegar  operation,  but  made  more  extensively  than  common.  It  has  seemed 
to  me  unnecessary,  in  my  experience,  entirely  to  close  the  vagina;  although 
in  elderly  women,  if  the  mucous  membrane  of  the  uterus  is  excised  and 
the  cervix  is  amputated,  there  is  no  special  objection  to  this  procedure; 
but  the  vagina  can  be  narrowed  enough,  I  think  to  dispense  with  it. 

In  the  preliminary  dissection  for  the  operation,  hemorrhage  should  be 
avoided  as  carefully  as  possible  and  perfect  hsemostasis  should  be  secured 
before  suturing  the  uterus,  especially  in  those  structures  which  will  eventually 
lie  above  it  and  cannot,  therefore,  be  properly  drained.  By  carelessness  in 
this  particular,  I  have  had  some  troublesome  hsematomata  which  had  to  be 
opened  above  the  sjinphysis.    It  is  quite  a  common  experience  to  have  a 


72  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

hsematoma  between  the  uterus  and  the  vaginal  flap,  although  this  can  be 
avoided  by  careful  technic  in  the  operation.  Should  it  occur,  however, 
there  is  not  much  harm  done.  For  a  while  the  patient  has  some  fever  and 
pain,  but  by  elevating  the  head  and  shoulders  or  the  head  of  the  bed,  and 
applying  hot  fomentations  to  the  vulva,  a  spontaneous  discharge  soon 
occurs  and  the  symptoms  subside. 

As  Wat  kins  advises,  I  have  avoided  gauze  drainage  in  the  operation, 
for  which  there  should  be  no  occasion  and  which  rather  predisposes  to 
infection  than  otherwise. 

Should  a  protrusion  of  the  fiuidus  uteri  develoji,  an  excision  of  the 
protruding  part,  with  suture  of  the  wound,  usually  removes  the  symptoms 
and  corrects  the  physical  defect. 

Too  wide  a  separation  of  vagina  from  bladder  and  of  bladder  from 
uterus  should  be  avoided,  as  such  dissection  may  interfere  with  the  inner- 
vation of  the  l)ladder  and  might  possibly  explain  the  occasional  cases  of 
incontinence  of  urine  following  an  interposition.  Watkins  attributes  this 
incontinence  of  urine  to  insufhcient  care  about  fastening  the  fundus  uteri 
well  forward  directly  under  the  urethra;  but  I  have  seen  some  cases  in  which 
the  fundus  uteri  was  carefullj^  anchored  in  the  proper  place  but  in  which 
incontinence  of  urine  developed.  I  attributed  it,  in  these  cases,  to  an 
imnecessarily  wide  isolation  of  the  bladder,  which  since  then  I  have  avoided. 
There  has  been  in  my  experience  one  unavoidable  disadvantage  of  the 
interposition  operation  in  a  considerable  number  of  cases — the  bulging  of 
the  uterine  body  into  the  base  of  the  bladder  and  distortion  of  the  course 
of  the  ureters  and  their  openings,  resulting  in  vesical  irritability;  but  in 
time,  after  the  tissues  become  accustomed  to  the  new  arrangement,  this 
symptom  usually  disappears.  It  has,  however,  persisted  for  a  discouraging 
length  of  time  in  some  of  my  patients  without  a  true  cystitis,  cystoscopy 
showing  a  normal  bladder  mucous  membrane. 


PLATE  XLII. 


Incision  for  diminishing  bulk  of  uterine  body. 


PLATE  XLUI. 


Method  of  blunt  dissection  of  anterior  vaginal  wall. 


PLATE  XLIV. 


Sterilization  of  patient  by  resection  of  the  tub?  in  the  interposition  operation. 


PLATE  XT  A'. 


Schauta  technic  of  interposition  operation  with  sterilization  by  section  of  tubes. 


REPAIR  OF  INJURIES  OF  ANTERIOR  VAGINAL  WALL  77 

Cystocele  Alternative  Procedures. — If  the  woman  is  still  young,  li\ing 
with  her  husband,  with  prospects  of  future  child-bearing,  an  interposition 
is  not  the  suitable  operation.  What  should  be  selected  in  such  cases  is  still 
open  to  discussion.    There  is  not  yet  a  general  agreement  upon  the  subject. 

My  choice  is  for  the  operation  illustrated  in  Plates  LXVI-LXIX.  I 
am  aware,  from  experience  with  it,  of  the  advantages  of  the  Goffe  operation 
(Plates  L-LII),  sewing  the  base  of  the  bladder  to  a  high  le\-el  on  the 
anterior  face  of  the  uterus  and  broad  ligaments,  in  cases  in  which  the 
uterus  was  well  supported  in  good  position;  and  I  have  used  it  with  satis- 
faction, often  in  combination  with  the  operation  illustrated  in  Plates  XLVI- 
XLIX.  I  have  also  on  occasion  utilized  other  operations  for  this  purpose — 
such  as  the  one  performed  in  the  ^Ia3'o  clinic,  which  consists  in  a  supra- 
\'aginal  amputation  of  the  uterus  and  the  interposition  of  the  broad  ligaments 
— a  useful  procedure  if  there  is  menorrhagia  from  a  myopathic  uterus  as 
well  as  a  cystocele.  But  I  have  modified  tliis  procedure  by  making  three 
stumps  of  each  broad  ligament  and  interposing  these  stumps  under  the 
l)ladder  which  gives  a  firmer  sujiport  than  the  outspread  broad  ligaments 
of  the  Alayo  operation. 

But  it  appears  to  me  that  a  radical  procedure  is,  as  a  rule,  inappro- 
priate under  the  circumstances  in  the  j'oung,  child-bearing  woman.  The 
operation  I  employ  has  the  advantages  of  not  opening  the  peritoneal  cavity 
nor  subjecting  the  woman  to  any  risk,  and  it  alters  in  no  way  the  anatomical 
arrangement  of  the  parts. 

It  must  be  confessed  that  there  is  a  larger  proportion  of  failures  after 
this  procedure  than  I  would  like  to  admit,  but  the  vast  majority  of  cases 
are  satisfactorily  cured.  Another  disadvange  is  the  possible  recurrence  of 
the  damage  in  case  the  woman  has  another  child  and  the  necessity  of 
another  operation.  The  Goffe  operation  has  a  decided  advantage  in  this 
respect,  but  it  requires  a  perfect  position  and  adequate  support  of  the 
uterus;  which  is  by  no  means  always  present  nor  can  it  always  be  secured 
in  cases  requiring  an  operation  for  cystocele. 

If  it  is  decided  to  interpose  the  uterus  between  the  bladder  and  the 
\agina  in  women  who  might  afterward  concei\'e,  the  tubes  should  be  re- 
sected for  about  an  inch,  the  ends  fastened  to  the  back  wall  of  the  uterus, 
and  the  wound  in  tlie  cornua  carefully  sewed  over  with  a  two-tier  stitch 
so  as  to  close  the  opening  of  the  interstitial  portion  of  the  tube;  but,  in 
spite  of  this  technic,  conception  may  occur.  It  did  so  in  three  of  my  patients 
the  pregnancy,  however,  in  each  instance  ending  in  an  abortion. 


PI>ATK   XLVI. 


Blunt  dissection  of  anterior  wall  to  expose  the  pelvic  fascia. 


PLATE   XL\II 


L'terovesical  ligament  cut. 


PLATE   XLVIII. 


The  bluddfT,  freed  from  its  attachment,  pushed  upward  and  autures  inserted  to  pull  the  fascia 

together  in  the  midline. 


PLATE   XLIX. 


Redundant  flap  of  mucous  membrane  out  away. 


PI.ATK    L. 


Goffe's  operation — sutures  inserted  in  the  prolapsed  bladder. 


PLATE  I.I. 


Sutures,  already  inserted  in  the  bladder  wall,  being  now  inserted  in  the  anterior  face  ol  the  uterus  and  the  anterior 

layers  of  the  broad  ligament. 


PLATE   LII. 


Sutures  tied,  bringing  tlie  prolapsed  bladder  to  a  higher  level  in  the  pelvis. 


INJURIES  OF  THE  CERVIX  85 

INJURIES  OF  THE  CERVIX 

These  injuries  may  be  a  longitudinal  or  a  transverse  laceration.  In 
the  latter  case,  the  whole  cervix  or  a  part  of  it  is  torn  off  at  the  vaginal 
junction.  If  the  separation  is  a  partial  one,  a  tab  of  cervical  tissue  remains 
attached  to  the  uterus  which  must  usually  be  removed  by  amputation 
(Plate  LIII-LV).  If  the  detachment  has  been  complete,  the  whole  cervi.x 
in  the  shape  of  a  ring  being  torn  off  from  its  attachment,  no  surgical  treat- 
ment, as  a  rule,  is  reciuired.  There  is  surprisingly  little  hemorrhage  and  the 
case  is,  in  effect,  one  of  amputation  of  the  cer\  ix,  leaving  a  symmetrical 
circular  scar  at  the  vaginal  vault. 

A  longitudinal  laceration  may  be  unilateral,  bilateral,  or  multiple, 
commonly  called  stellate.  The  unilateral  tear  usually  requires  no  surgical 
attention  because  there  is  not,  as  a  rule,  an  a.ssociated  eversion  and  erosion. 
A  bilateral  tear,  if  moderate  in  extent  and  not  associated  with  erosion  and 
eversion,  may  also  be  left  unrepaired.  It  is  better  to  have  a  wide  opening 
of  the  cervical  canal  with  good  drainage  than  to  close  the  cervical  canal 
too  tightly.  If,  however,  there  is  erosion  and  eversion  or  much  infiltration 
of  scar  tissue  at  the  upper  angles  of  the  tear,  a  repair  is  indicated  by  the 
well-known  technic  of  Emmet,  which  has  never  been  improved  upon  in 
the  ordinary  uneomphcated  bilateral  cervical  laceration. 

If  the  tear  is  stellate,  if  there  is  marked  erosion  of  the  whole  vaginal 
portion,  if  there  is  extensive  cicatricial  infiltration,  an  amputation  of  the 
cervix  is  indicated.  As  a  rule  this  is  best  done  by  a  circular  incision  at  the 
vaginal  junction.  Other  methods  have  been  proposed  bj-  which  a  combina- 
tion of  amputation  of  the  two  lips  separately  with  Emmet  trachelorrhaphy 
may  be  employed,  or  the  flap  may  be  made  longer  on  the  vaginal  surface 
of  the  cervix  than  in  the  cervical  canal,  thus  turning  in  health}-  squamous 
epithelium  into  the  canal  instead  of  unhealthy,  hj'pertrophied  and  inflamed 
columnar  epithelium  (Plates  LVI-LIX). 

In  occasional  cases  these  modifications  are  obviously  indicated;  but 
in  most  cases  in  which  the  Emmet  trachelorraphy  is  not  suitable,  the  pro- 
cedure usually  adopted  is  the  Hegar  amputation  of  the  second  type  which 
Hegar  devised,  with  sutures  inserted  in  such  a  manner  that  the  wound  is 
dog-eared  on  each  .side  out  into  the  lateral  vaginal  vault;  two  sutures  are 
put  in,  making  a  lineal  wound  in  this  region,  on  each  side.  Two  other  sutures 
each  are  usually  required  to  close  the  wound  in  the  anterior  and  the  pos- 
terior lip  which,  as  they  are  amputated,  are  cut  away  in  such  a  manner  as 
to  leave  a  wedge-shaped  excision  so  that  the  two  portions  of  the  excised  lip 
may  be  brought  together  in  nice  approximation. 

A  superficial  stitch  is  often  required  between  the  two  lateral  sutures 
and  the  sutures  in  the  anterior  and  posterior  lip;  but  care  must  be  exercised, 
in  inserting  these  sutures,  not  to  close  the  cervical  canal  too  tightly.    In 


86  ATLAS  OF  OPERATIVE  GYN.ECOT>OGY 

spite  of  an  effort  to  a\oid  this  inistake,  there  are  few  operators,  I  think,  who 
have  not  occasionally  made  it.  One  must  be  on  his  guard,  therefore,  to 
leave  a  wide  canal  to  insure  good  drainage,  otherwise  an  acquired  stenosis 
of  the  cervix  will  leave  the  woman  in  a  worse  state  than  she  was  with  the 
condition  for  which  the  cervix  was  amputated. 

The  suture  material  in  the  cervix  should  be  a  number  3  size  chromic 
gut.  The  tissues  are  tough;  there  is  some  strain  upon  the  sutures,  so  that 
a  smaller  size  will  very  likely  suffer  premature  absorbtion  and  give  way, 
with  the  certain  result  of  a  gaping,  unhealed  wound  and  a  possibility  of 
quite  a  severe  hemorrhage  during  convalescence  from  the  operation. 


PLATE  LIII. 


Amputation  of  cer\ix. 


PLATE  LIV. 


Sutures  for  amputated  cervix. 


PLATE  LV. 


Sutures  united. 


IM,ATK   LVI, 


Trachelorrhaphy. 


PLATE  LVII. 


Excision  of  6aps. 


PLATE  L\'III. 


tititches  inserted. 


PLATE  LIX. 


Stitches  tied. 


94  ATLAS  OF  OPERATIVE  GYN.ECOLOGY 

FISTULiE  OF  THE  UROGENITAL  TRACT 

Vesicovaginal  fistulte,  a  common  sequence  of  labor  in  the  past  genera- 
tion, are  now  rarely  seen  as  one  of  the  injuries  of  parturition.  The  fistula? 
encountered  at  present  are  almost  always  the  result  of  an  operation  such  as 
hysterectomy  or  an  anterior  vaginal  hysterotomy.  Their  situation  and 
extent,  therefore,  are  quite  different  from  the  fistulae  usually  following 
labor.  The  latter  are  commonly  fountl  about  midway  between  the  x'aginal 
entrance  and  the  cervix  in  the  center  of  the  anterior  vaginal  wall.  The 
fistula  is  usually  moderate  in  size  and  round  in  shape.  It  is  easih'  accessible 
and  usually  easily  repaired.  The  typical  operation  consists  in  the  separation 
of  the  vaginal  and  bladder  walls  around  the  fistulous  opening  for  the  space 
of  about  one-half  inch.  The  bladder  wall  is  then  closed  by  numl)er  1  catgut 
sutiires  put  in  transversely  in  such  a  manner  that  they  do  not  include  the 
mucous  membrane,  but  bring  together  the  inner  layer  of  the  denuded  surface 
and  the  outer  bladder  wall  surrounding  the  opening  into  the  bladder.  The 
vaginal  wound  is  closed  at  right  angles  to  the  one  in  the  bladder  or  on  the 
bladder  wall,  the  sutures  being  inserted  through  the  vaginal  miicous  mem- 
brane and  the  subjacent  denuded  area,  usually  put  in  from  above  downward 
as  there  is  conunonly  some  redundance  of  mucous  membrane  of  the  anterior 
vaginal  wall,  the  slack  of  which  is  taken  up  in  this  manner  (Plates  LX,  LXI). 
For  these  vaginal  sutures  I  prefer  fine  linen  thread  following  the  suggestion 
of  Fritsch  of  C.ermany,  who  had  the  largest  experience  in  the  repair  of  this 
condition  possessed,  I  believe,  by  any  surgeon,  his  work  l^eing  on  the  eastern 
border  of  Prussia,  where  attendance  on  labor  cases  is  in  large  part  by 
ignorant  midwives,  and  where  this  particular  consequence  of  a  neglected 
labor  was  unusually  conunon. 

After  the  closure  of  the  vesical  and  vaginal  wounds  the  bladder  is 
drained  by  a  mushroom  catheter  for  foiu-  days;  after  that,  for  a  couple  of 
days,  the  woman  should  be  catheterized  every  four  hours;  she  then  should 
be  allowed  to  ]:)ass  water  naturally.  While  the  nmshroom  catheter  is  in 
place,  the  nurse  attaches  a  funnel  to  the  catheter  twice  a  day,  through 
which  is  poured  into  the  bladder  two  ounces  of  boracic  acid  solution,  which 
clears  the  eye  of  the  catheter  and  helps  to  keep  the  bladder  clean.  .At  other 
times  the  mushroom  catheter  is  jointed  by  a  short  glass  tube  to  a  longer 
rubber  tube,  which  is  led  into  a  jar  containing  boracic  acid  solution  tied  to 
the  side  of  the  woman's  bed ;  in  this  the  end  of  the  rubber  tube  is  submerged. 
The  linen  stitches  in  the  vagina  need  not  be  removed  for  some  time  after  the 
operation.  I  am  in  the  habit  of  letting  the  woman  leave  the  hospital  with 
directions  to  return  in  a  couple  of  weeks  or  longer,  the  sutures,  therefore, 
remaining  in  place  some  four  to  six  weeks  from  the  time  they  were  in.serted. 

Fistulae  between  the  vagina  and  the  bladder  are  not  always  so  easily 
accessible;  nor  so  moderate  in  size  and  regular  in  contour.     Ihey  may  be 


FISTUL.E  OF  THE  T  ROGENITAL  TRACT  95 

situated  hig:h  in  the  anterior  vaginal  vault;  they  may  involve  almost  the 
whole  anterior  vaginal  wall  and  base  of  the  bladder  with  even  a  portion  of 
the  urethra.  There  is  no  operation  which  demands  so  much  individual 
study  or  such  individual  differences  in  technic.  I  have  been  obliged  to  use 
the  cervix  as  a  plug  to  till  up  the  hole  in  the  bladder  for  which  it  was  impos- 
sible to  secure  sufficient  tissue  from  the  vaginal  wall.  The  fistula  was 
caused  by  a  neglected  ring  pessary  and  admitted  fourfingers  into  the  bladder. 
In  some  cases  I  have  utilized  the  corpus  uteri,  pulled  out  through  the  anterior 
\aginal  wall,  as  a  plug  to  close  a  defect  involving  the  whole  base  of  the  blad- 
der. If  the  fistula  is  situated  high  in  the  anterior  vaginal  vault,  it  may  be 
necessary,  as  suggested  by  Ward  of  New  York,  to  dissect  the  vaginal^wall 
free  from  the  bladder  beginning  directly  under  the  urethra  and  exteniling 
the  dissection  up  to  the  vaginal  vault;  that  is  to  say,  beginning  the  dissection 
in  the  region  not  affected  by  scar  tissue  and  approaching  the  area  of  injury 
after  the  plane  of  separation  between  vagina  and  bladder  is  plainly  outlined 
by  dissection  in  the  uninjured  portion  of  the  urogenital  septum.  Occasion- 
ally, in  order  to  get  access  to  such  a  fistula,  it  is  necessary  to  utilize  the 
Schuchardt  incision  shown  in  Plate  LXII.  It  may  be  sufficient  to  enlarge 
the  vaginal  opening  by  bilateral  incisions  not  so  extensive  as  those  of 
Schuchardt. 

In  closing  fistulse  extending  a  considerable  distance  transversely,  care 
nuist  be  exercised  to  locate  the  ureteral  orifices,  which  otherwise  might  be 
buried  in  the  denuded  surface  or  occluded  by  a  suture. 

In  suturing  a  denuded  area  around  or  a  transplanted  flap  over  a  vesical 
fistula,  the  needle  must  not  penetrate  the  vesical  mucous  membrane.  If 
it  does,  an  intravesical  hemorrhage  will  probably  result  in  failure  of  the 
operation  or  the  suture  tract  may  develop  into  another  fistula.  Acquired 
atresia  of  the  vagina  is  a  method  of  spontaneous  cure  not  infrequently  seen. 
If  the  patient  has  passed  the  menopause,  she  remains  comfortable:  but 
if  she  menstruates  into  the  bladder,  there  may  be  severe  distress  at  the 
periods;  and,  if  the  lower  portion  only  of  the  vaginal  canal  is  closed,  a  sac 
exists  beneath  the  level  of  the  fistula  in  which  blood,  pus,  and  decomposed 
urine  collect.  It  is  occasionally  impossible  to  close  a  serious  defect  in  the 
posterior  wall  and  base  of  the  bladder.  In  such  cases  a  colpocleisis  is  jus- 
tifiable, if  the  precaution  is  taken  to  close  the  canal  up  to  the  level  of  the 
fistula,  leaving  no  vaginal  sac  below  for  the  retention  of  decomposed  urine 
and  menstrual  discharge. 

Fritsch  has  closed  a  fistula  by  denuding  the  anterior  surface  of  the  pos- 
terior lip  of  the  cer\ix  in  a  case  of  defect  of  the  anterior  lip  and  implanting 
the  posterior  lip  in  the  \esical  opening.  The  woman  menstruated  into  the 
bladder,  but  nevertheless  remained  comfortable  for  years. 

To  close  the  vagina  (colpocleisis)  a  circular  denudation  is  made  around 


S)(i  ATLAS  OF  OPERATIVE  (iYN^ECOLOGY 

the  whole  canal  two  ccutinieters  l)roa(l,  at  a  8ufficieut  height  to  preclude 
the  formation  of  a  sac  below  the  level  of  the  fistula;  a  row  of  interrupted 
sutures  across  the  vagina,  inserted  frpm  before  backward,  closes  the  canal. 
In  difficult  cases  of  extensive  fistula?  deep  within  the  vagina,  and  of  fixation 
of  the  bladder  by  cicatricial  adhesions,  tlie  following  procedures  ha\e  been 
advocated  and  adopted : 

Incision  into  the  anterior  bladder-wall  by  suprapubic  cystotomy  in 
the  Trendelenburg  posture  and  closure  of  the  fistula  from  above,  silk 
ligatures,  if  they  are  used,  being  left  long  and  led  out  of  the  urethra,  whence 
they  are  removed  by  traction  after  they  have  cut  through  the  tissue;  or 
buried  catgut  sutures  may  l)e  employed  (Trendelenburg). 

A  transverse  incision  over  the  pul)is,  freeing  the  bladtler,  and  closure 
of  the  fistula  i'roui  the  vagina  (Fritsch). 

Separation  of  the  \'agina  from  the  bladder  around  the  fistula,  closure 
of  the  opening  in  the  bladder,  and  a  separate  closure  of  the  vaginal  wound, 
as  in  anterior  colporrhaphy  (Winternitz,  Mackenrodt). 

Opening  Douglas's  pouch,  retroverting  the  uterus  into  the  vagina, 
using  its  posterior  siu'face  (which  becomes  anterior  in  the  complete  retro- 
version) as  a  plug  to  fill  in  a  large  defect  in  the  vesicovaginal  septum,  and 
making  an  artificial  os  in  the  fundus  to  allow  the  escape  of  menstrual  dis- 
charge (Freund).  I  modified  this  procedure  in  one  instance  by  pulling  the 
uterus  out  through  the  anterior  vaginal  vault  and  fastening  it  imder  the 
symphysis. 

If  the  urethra  is  absent  or  partly  destroyed,  its  restoration  is  always 
doubtful.  The  most  hopeful  plan  is  to  ])rei)are  a  flap  of  mucous  membrane 
as  thick  as  possible  from  one  side,  to  ttu'n  it  inward  so  as  to  bring  the  nmcous 
surface  within  the  newly  made  canal,  and  to  fasten  it  in  a  denuded  area  on 
the  opposite  side.  The  new  urethra  should  be  established  before  the  vesical 
fistula  is  closed. 

Fortunately,  continence  may  be  established  without  the  presence  of  a 
urethra  by  leaving  a  narrow  orifice  at  the  neck  of  the  bladder.  This  was 
accomplished  in  one  of  my  cases  after  several  futile  attempts  to  construct 
a  new  urethra,  which  was  entirely  lacking,  directly  back  of  the  external 
meatus. 

If  there  is  such  a  serious  defect  of  urethra  and  base  of  bladder  that  no 
plastic  operation  succeeds  in  restoring  e\-en  partial  continence,  colpocleisis 
and  a  rectovaginal  fistula  may  make  the  i:)atient's  condition  endurable.  But, 
if  there  is  a  cystitis  at  the  time  of  operation,  the  result  may  be  fatal  from  an 
exacerbation  of  the  inflammation  and  infection  of  the  ureters  and  kidneys. 
Indeed,  there  is  always  danger  of  pyelonephritis  after  such  an  oj^eration, 
though  occasionally,  as  in  one  of  Fritsch's  cases,  the  patient  remains  com- 
fortable and  well  for  years. 


PISTUL.E  OF  THE  UROGENITAL  TRACT  ^ 

The  rectovaginal  fistula,  admitting  a  forefinger,  should  be  made  by  a 
transverse  incision  just  abo\e  the  sphincter  ani,  the  vaginal  and  rectal 
mucous  membranes  being  united  by  interrupted  sutures  of  catgut.  The 
vaginal  orifice  is  then  closed.  A  double  rubber  drainage-tube  is  inserted 
through  the  fistula,  and  during  the  patient's  convalescence  the  vesico- 
vaginal pouch  is  frequenth^  irrigated  with  a  boracic  acid  solution. 

If  a  ureter  has  been  included  in  one  of  the  stitches,  there  are  symptoms 
of  deficient  urinary  secretion,  rapid  pulse,  pain  in  the  back,  a  tendency'  to 
somnolence,  and  sometimes,  though  rarely,  high  fever.  There  are  two 
courses  open  to  the  operators:  one  is  to  remove  the  stitches  and  to  do  the 
operating  over  again;  the  other  is  to  tru.st  to  nature  to  overcome  the  diffi- 
culty, which  is  often  done  by  the  stitch  cutting  through,  by  the  urine  under 
pressure  forcing  its  way  through  the  loop  of  the  ligature,  or  by  the  establish- 
ment of  a  uretero-vaginal  fistida.  Occasionally  the  kidney  on  the  affected 
side  atrophies  and  the  remaining  kidney  performs  the  work  of  two,  as  after 
a  nephrectomy'. 

If  there  is  a  persistence  of  incontinence  after  the  operation,  the  flow  of 
urine  may  come  from  a  suture  track,  from  a  failure  of  union  at  some  part  of 
the  wound,  or  from  a  second  fistula  not  detected  at  the  time  of  operation. 
The  last  two  conditions  reciuire  subsequent  operations.  A  small  suture- 
track  fistula  often  closes  spontaneously,  and  some  time  should  be  allowed 
for  this  result  before  subjecting  the  patient  to  a  second  operation,  which 
might  be  unnecessary. 

Intravesical  hemorrhage  will  not  occur  after  an  operation  for  vesico- 
vaginal fistula  if  the  sutures  are  properly  placed.  If  it  does,  it  is  an  awkward 
complication.  The  bladder  should  be  washed  out  with  boracic  acid  solution 
every  two  hours  to  prevent  the  formation  of  a  large  clot.  If  a  clot  does 
form  in  the  bladder,  causing  tenesmus,  the  injection  of  pepsin  solution  has 
been  recommended  to  soften  it,  but  from  recent  experience  with  it  a  citrate 
of  sodium  solution  2  per  cent,  would  seem  better. 

Occasionally  the  fistulous  opening  between  genital  and  urinary  tract 
is  found  within  the  cervical  canal.  To  reach  it,  it  may  be  necessary  to  cut 
the  cervix  in  two  bilateralh'  and  then  to  separate  the  anterior  lip  of  the 
cervix  from  the  vaginal  vault  and  the  bladder  wall,  the  hole  in  the  latter 
being  sewed  separately  by  the  technic  already  described. 


PTvATK   LX, 


Map  splitting  denutUition  for  vesicovnginal  fistula. 


Pr.ATK  LXI. 


Stitches  in  bladder  wall  and  vagina  inserted  at  right  angles.     1  tie  i'>riii>  r  must  naturally  be  tied  bei" 

the  latter  are  inserted. 


TATK  r.xn. 


Schuchardt's  incision  completed. 


URETERAL  FISTULA  101 

URETERAL  FISTULA 

There  may  be  a  communication  between  the  ureter  and  the  genital 
tract  in  women;  the  fistulous  opening  may  be  into  the  vagina  or  into  the 
cervix.  The  recognition  of  the  ureteral  fistula  is  easy.  There  is  a  constant 
dribbling  of  urine,  while  at  the  same  time  half  the  urine  is  passed  naturally 
by  the  bladder.  By  cystoscopy  and  the  catheterization  of  the  ureters  there 
is  additional  confirmation  of  the  existence  of  a  ureteral  fistula.  There  are 
three  kinds  of  surgical  treatments  for  these  fistulse:  nephrectomy,  a  plastic 
operation  in  the  vagina,  and  an  abdominal  section  followed  by  the  junction 
of  the  ureter  or  its  implantation  in  the  bladder. 

Nephrectomy  and  the  abdominal  operation  to  join  the  ureter  by  an 
end-to-end  or  bilateral  implantation  may  be  required  in  any  sort  of  patient — 
man,  woman,  or  child.  The  only  operations  peculiar  to  women  are  those 
in  the  vagina.  Consequently  I  confine  myself  to  a  description  of  the  opera- 
tive treatment  of  ureteral  fistulse  in  a  vaginal  operation. 

The  Vaginal  Operations  for  Ureteral  Fistula.  -The  first  requi- 
site for  a  successful  plastic  operation  by  the  vagina  is  to  find  the  upper 
end  of  the  ureter  and  its  orifice,  which  is  not  always  easy  to  do.  If  there  is 
not  too  much  scar  tissue  the  ureter  may  be  dissected  out,  implanted  into 
an  incision  made  into  the  bladder,  and  fastened  in  place  by  several  inter- 
rupted sutures  of  fine  catgut.  The  vaginal  wound  is  closed  over  the  end  of 
the  ureter  and  the  opening  in  the  bladder  into  which  it  has  been  implanted 
(Parvin,  Mc Arthur).  It  has  sometimes  been  possible  to  sew  the  mucous 
membrane  of  the  bladder  to  the  mucous  membrane  of  the  ureter  and  so  to 
fasten  the  latter  in  place.  The  vaginal  mucous  membrane,  dissected  back 
on  each  side  by  a  flaji-splitting  dissection,  is  united  over  the  ureter  and 
the  newly  made  opening  into  the  bladder. 

Schede's  Operation: — This  operation  has  given,  on  the  whole,  the  best 
results:  A  vesicovaginal  fistula  is  made  close  by  the  ureteral  fistula,  the 
mucous  membrane  of  the  bladder  and  that  of  the  vagina  being  united  by 
interrupted  sutures  of  catgut;  an  oval  denudation  is  made,  one  centimeter 
wide,  around  both  the  ureteral  and  the  vesical  fistulae,  leaving  a  strip  of 
undenuded  membrane  0.5  centimeter  wide,  immediately  surrounding  both 
fistulse.  The  denuded  surfaces  are  united  by  interrupted  sutures,  thus 
directing  the  stream  of  urine  from  the  ureter  into  the  bladder. 

BandVs  Operation: — This  is  only  practicable  if  both  ends  of  the  ureter 
are  discoverable  and  are  normally  patent.  A  ureteral  catheter  is  passed 
into  both  the  lower  and  the  upper  segments  of  the  ureter,  emerging  from  the 
urethra.  A  denudation  is  made  and  united  as  in  Schede's  operation,  but 
without  making  a  vesicovaginal  fistula.  If  the  catheter  is  fenestrated  the 
whole  bladder  is  drained  by  it,  or  the  urethra  may  be  drained  by  a  rubber 
tube  through  which  the  ureteral  catheter  passes. 


102  ATLAS  OF  OPERATIVE  GYNJ^/ OLOGY 

Mackenrodt's  Operation. — A  very  ingenious  procedure,  which  has  been 
successful  in  the  few  cases  in  which  it  was  tried.  A  vesicovaginal  fistula 
is  made  near  the  ureteral  fistula.  A  semicircular  thick  flap  of  vaginal 
mucosa  is  dissected  ofT,  so  that  it  carries  the  ureteral  opening  in  its  center, 
has  its  attached  base  next  to  the  vesicovaginal  fistula,  and  its  free  edge 
away  from  it.  By  turning  this  flap  over  a  half  circle  on  its  base  it  closes 
the  vesicovaginal  fistula  like  a  lid;  it  is  sewed  in  place  by  catgut  sutures 
with  the  vaginal  nuicous  membrane  directed  into  the  bladder,  and  so  turning 
the  ureteral  fistula  into  the  bladder.  The  raw  surfaces  left  by  the  removal 
of  the  flap  and  over  the  vesicovaginal  fistula  are  united  with  interrupted 
sutures  or  are  allowed  to  granulate. 

Dudley's  Operation.  ^\s  Reynolds  says,  this  is  a  crude  procedure,  but 
it  has  succeeded  when  other  plans  have  failed.  A  sharp-pointed  artery  or 
other  similar  forceps  is  passed  into  the  urethra;  a  vesicovaginal  opening  is 
made;  one  blade  of  the  forceps,  which  is  opened  for  the  purpose,  is  pushed 
out  of  the  incision  in  the  bladder;  the  renal  end  of  the  ureter  is  threaded  on 
it ;  the  handles  of  the  instrument  are  closed  and  tied,  thus  clamping  the  end  of 
the  ureter  to  the  bladder  wall.  The  forceps  is  lightly  pulled  upon  after  eight 
or  ten  days.     If  it  does  not  come  away  it  is  opened  and  extracted. 

OPERATIVE  TREATMENT  FOR  RETROVERSION  OF  THE  UTERUS 

Retroversion  of  the  uterus  ranks  second  in  frequency  after  lacerations 
of  the  birth  canal  among  the  affections  peculiar  to  women — that  is,  leaving 
out  endometritis  or  hyperplasia  of  the  endometrium,  which  accompanies 
almost  all  pathological  conditions  of  the  pelvic  organs,  but  which  as  an 
entity  or  a  disease  entirely  by  itself  is  very  rare.  Retrodisplacement  of  the 
uterus  constitutes  10  per  cent,  or  more  of  all  the  diseases  of  women,  so  that 
a  .surgeon  who  learns  the  best  operative  treatment  for  these  two  conditions 
is  in  a  position  to  deal  successfully  with  60  per  cent,  or  more  of  the  women 
who  apply  to  him  on  account  of  some  disease  peculiar  to  their  sex. 

There  is  considerable  difference  of  opinion  as  to  the  necessity  for  the 
operative  treatment  of  retrodisplacement  of  the  uterus,  but  no  one  can  have 
seen  much  of  the  diseases  of  women  without  admitting  that  there  are  main- 
cases  demanding  the  relief  which  can  only  be  afforded  the  woman  by  an 
operation.  The  alternative,  the  use  of  a  pessarj-,  has  so  manj-  disad- 
vantages that  it  is  more  and  more  rarely  resorted  to  except  as  a  tem- 
jjorary  measure. 

The  operative  treatment  of  retroversion,  however,  is  a  matter  of 
choice  for  the  patient.  My  practice  is  to  state  the  relative  advantages  and 
disadvantages  of  the  two  procedures,  pointing  out  that  the  pessary  must 
be  removed  e\-ery  six  weeks;  that  it  must  occasionally  be  left  out  altogether 
on  account  of  ulcerations  of  the  vagina;  that  it  never  promises  a  permanent 


OPERATIVE  TREATMENT  FOR  RETRO^  ERSION  OF  UTERUS   103 

cure — on  the  contrary,  by  stretching  the  ligaments,  it  makes  the  displace- 
ment more  difficult  to  manage  without  artificial  support  than  if  the  pessary 
had  never  been  employed;  and  it  must  be  worn  indefiniteh'.  Some  patients, 
however,  insist  on  the  use  of  a  pessarj'.  There  are  women  coming  to  my  office 
now  at  regular  intervals  who  began  this  treatment  twentj^-five  years  ago. 

After  a  trial  of  this  palliative  measure,  which  many  patients  demand  at 
first,  I  find  that  the  vast  majority  of  women  deliberately  select  the  operative 
treatment ;  while,  if  that  treatment  were  urged  upon  them  in  the  beginning, 
they  would  be  inclined  to  become  apprehensive  and  perhaps  change  their 
physician ;  whereas,  if  operation  is  ultimately  selected  by  the  patient  herself, 
the  original  attendant  ma}'  perform  it  if  he  desires  to  do  so. 

It  is  true  that  there  are  some  patients  who  show  surprisingly  few 
symptoms  from  a  retrodisplaced  uterus.  The  young  unmarried  girl,  the 
woman  who  has  not  borne  children;  even  the  woman  who  has  borne  children 
and  who  may  have  some  tendency  to  prolapse,  as  well  as  retrodisplacement, 
occasionally  suffers  nothing  apparently  from  the  condition  of  the  pelvic 
organs.  But  these  patients  are  the  exception.  Even  in  the  unmarried  girl 
there  are  often  severe  symptoms  not  only  localh'  but  referred,  as  head- 
aches, pain  in  the  neck,  often  coccygeal  pain,  associated  with  serious 
nervous  disturbances. 

I  have  had  several  cases  of  actual  epilepsy  associated  with  retro- 
displacement  of  the  uterus,  cured  by  the  operative  treatment  of  that 
condition. 

Retrodisplacement  of  the  uterus  is  also  not  infrequently  a  cause  of 
sterility,  and  the  treatment  of  the  woman's  sterility  must  include  the  per- 
manent reposition  of  the  uterus  and  its  retention  in  a  normal  position. 

The  unsatisfactory  result  of  manj'  of  the  operations  performed  for 
retroversion  of  the  uterus  have  in  some  quarters  created  a  prejudice  against 
this  treatment,  but  I  feel  that  the  improvement  in  this  operation  recently 
secured  by  a  combination  of  two  of  the  older  plans  will  be  found  to  give 
such  uniformly  good  results  that  this  source  of  prejudice  against  the  opera- 
tive treatment  of  uterine  displacement  will  be  removed  by  future  experience. 

Another  cause  of  disappointment  with  the  operative  treatment  of  retro- 
version has  been  the  failure  on  the  part  of  many  operators,  especially 
general  surgeons,  to  take  into  account  the  associated  injuries  of  the  birth 
canal.  In  the  vast  majority  of  cases,  backward  displacement  of  the  uterus 
follows  the  process  of  generation  and  is  very  frequently  indeed  associated 
with  some  damage  of  the  genital  canal.  The  discomfort,  therefore,  which 
sometimes  persists  after  the  operative  cure  of  the  backward  displacement 
of  the  uterus  can  often  be  attributed  to  an  imperfect  correction  of  the 
injuries  of  child-birth  or  the  total  neglect  of  this  feature  in  a  given  case. 

If  there  is  no  indication  for  a  repair  of  the  injuries  in  the  genital  canal. 


104  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

there  is  almost  invariably  a  necessity  for  dilating  the  cervix  and  curetting 
the  uterine  cavity,  so  that  any  operation  for  retrodisplacenient  of  the  uterus 
forms  only  a  part  of  the  operative  procedure  undertaken. 

In  a  case  of  long  standing  there  is  ai)t  to  he  also  a  clironic  metritis 
with  enlargement  and  increase  in  the  weight  of  the  womb,  whi(^h  may  and 
probably  will  require  treatment  subsecjuent  to  the  operation.  If  all  these 
factors  are  taken  into  account,  and  if  the  best  operative  technic  is  selected, 
I  feel  conhdent  that  what  prejudice  exists  at  present  against  the  operative 
treatment  of  retroversion  will  eventually  disajij^ear. 

j\Iy  professional  life  embraces  in  point  of  time  almost  the  whole  history 
of  the  operative  treatment  of  retrodisjilacement,  from  the  susjiension  oi)er- 
ation  of  Olshausen  to  the  present  time. 

Many  of  the  numerous  operations  before  the  profession  I  have  tried  in 
series  of  cases  and  have  for  many  years  looked  for  the  ideal  ojioration  that 
would  make  the  ])atient  well  and  keep  her  so  in  s])ite  of  futuiv  childl)('aring. 
The  old  suspension  operation  introduced  into  this  country  by  Kelly,  the 
operation  of  Dr.  CJilliam  with  all  its  modifications,  Baldy's  ojjeration, 
Webster's  operation,  C'cffey's  operation,  as  well  as  the  older  operations  of 
Dudley  and  Mann,  have  all  been  tried  and  given  up.  It  is  only  during  the 
last  four  years  that  I  have  found  the  operation  which  meets  my  require- 
ments. While  my  ex]ierience  is  necessarily  limited  with  this  ]irocedure, 
in  the  comparati\'ely  short  time  during  which  I  haA'e  utilized  it,  although 
the  total  number  of  operations  is  now  over  two  hundred,  1  have  had  an 
experience  with  its  component  parts  over  a  period  of  more  than  twenty 
years,  so  that  I  know  well  what  each  one  of  these  operations  will  do  of  itself 
and  I  ha\'e  confidence  that  the  combination  of  them  will  give  me  what  I 
have  been  long  looking  for — a  procedure  that  will  not  only  symptomatically 
cure  the  patient,  but  will  permit  her  to  bear  children  in  the  future  without  a 
recurrence  of  the  displacement.  In  the  twenty  years  that  I  have  been  short- 
ening the  roiuid  ligaments  in  the  groin,  I  have  not  yet  seen  a  patient  with  a 
recurrence  after  a  subsequent  confinement.  It  is  remarkable  to  be  able  to 
make  this  statement,  but  it  is  a  true  one.  The  high  percentage  of  failures 
reported  by  some  observers  is  to  be  explained  by  an  imperfect  technic  in 
performing  the  operation. 

A  disadvantage  of  the  old  Alexander  operation,  however,  even  as 
modified  by  Edebohl  was  that  it  did  not  permit  an  inspection  of  the  appen- 
dix and  the  appendages.  I  lost  a  patient  once  on  this  account  from  an  appen- 
dicitis which  had  been  chronic  for  some  time  (it  probably  existed  at  the  time 
of  my  operation) ;  it  suddenly  became  acute  and  gangrenous.  The  jihysician 
in  charge  of  the  case  at  that  time  did  not  believe  in  the  immediate  operative 
treatment  and  by  the  time  the  patient  was  referred  for  operation  it  was  too 
late  to  save  her. 


OPERATIVE  TREATMENT  FOR  RETROVERSION  OF  UTERUS  105 

The  suspension  operation  is  a  useful  procedure  easily  and  quickly 
carried  out,  but  it  will  not  stand  the  strain  of  the  next  pregnancy,  and  has 
too  large  a  percentage  of  recurrences.  The  combination  of  the  two,  however, 
gives  me  exactly  what  I  have  been  looking  for.  The  temporary  suspension 
of  the  uterus  with  a  single  strand  of  number  3  plain  gut  keeps  the  uterus 
in  place  while  the  round  ligaments  are  being  set  in  their  new  position,  and 
takes  the  i)lace  of  the  pessary  it  was  customary  to  use  while  the  patient  was 


Fig.  20. — Pfannenstiel  incision  twelve  thiys  after  the  operation. 


recovering  from  the  old  Alexander  operation:  and  while  the  abdomen  is 
open  through  the  Pfannenstiel  incision  there  is  ample  opportunity  to  sever 
adhesions,  inspect  the  appendix  and  the  appendages,  and  do  what  may  be 
required  when  these  structures  are  exposed  to  touch  and  sight  (Plates 
LXIII-LXXIII). 

Another  advantage  of  this  procedure  in  the  young  child-bearing  woman 
is  the  practically  unscarred  abdomen  and  the  elastic  abdominal  walls  which 
remain  for  subsequent  child-bearing  (Fig.  20).    I  have  foimd  this  operation 


106  ATLAS  OF  OPERATIVE  GYN.^^XOLOdV 

also  peculiarly  suitable  to  those  cases  of  sterility  in  which  the  backward 
displacement  of  tlie  uterus  plays  a  causitive  role  in  the  prevention  of  con- 
ception. The  ojieration  not  only  jierniits  the  coi-i'ection  of  the  displacement, 
but  also  gives  an  oijjjortunity  for  the  inspection  of  the  ])elvic  organs  and  the 
detection  of  some  other  possible  bar  to  the  penetration  of  spermatozoa,  such 
as  closure  of  the  alxlominal  orifices  of  the  tubes,  adhesions  obstructing  the 
calil^er  of  the  tube,  and  adhesions  and  plastic  exudate  burying  the  ovary. 
The  intra-abdominal  work  in  this  (jpci'ation  is  usually  so  slight  and  so 
speedily  perfornunl  that  there  is  little  chance  for  subseciuent  adhesions  in 
consefiuence  of  the  abdominal  section,  and  the  symptomatic  relief  is  de- 
cidedly greater  than  is  afforded  by  those  operations  for  retroversion  done 
entirely  within  the  abdominal  cavity. 

The  Coffey  operation,  which  at  present  seems  to  be  most  popular  in 
this  coimtry,  has  this  disadvantage:  I  have  been  obliged  twice  to  reopen 
an  abdomen  in  order  to  relie^■e  the  excessi\-e  adhesions  sometimes  formed 
anteriorly  after  this  operation.  And  I  do  not  l)elieve  that  this  operation 
will  stand  the  strain  of  subsequent  pregnancies. 

By  the  follow-up  i^lan  of  writing  to  the  patient  a  year  after  the  perform- 
ance of  the  combination  of  suspension  of  the  uterus  and  shortening  of  the 
roimd  ligaments,  I  have  not  yet  failed  to  receive  a  favorable  report  from 
e\'ery  patient  from  whom  I  have  been  al)le  to  secure  a  reply  to  my  communi- 
cation, antl  so  far  I  ha\'e  not  found  a  recurrence  of  the  displacement  after 
this  operation. 

I  am  encouraged  to  believe,  therefore,  that  it  will  prove  as  satisfactory 
a  procedure  as  any  that  has  been  tried  for  the  operative  treatment  of  retro- 
version of  the  uterus.  In  my  experience  at  least  it  has  been  demonstrated 
to  be  a  much  more  satisfactory  operation  than  any  of  the  others  that  have 
been  tested. 


PLATE  LXIII. 


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Oferution  for  rptrovrrsion.     Pfaiinenstiel  inci^iin. 


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118  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

PROLAPSE  AND  INVERSION  OF  THE  UTERUS 

The  only  other  displacements  of  the  uterus  requiring  operative  treat- 
ment are  prolapse  and  inversion. 

I  have  never  been  convinced  of  the  necessity  for  operating  upon  cases 
of  antiflexion.  Of  itself,  this  displacement  is  responsible  for  no  symptoms 
except  dysmenorrluEa  and  sterility.  The  .former  is  due  more  to  the  ill- 
development  of  the  uterus  of  which  the  antiflexion  is  a  sign  than  to  the  dis- 
placement proper.  If  sterility  is  the  result,  it  is  due  to  mechanical  inter- 
ference with  the  ascension  of  the  spermatozoa  in  consequence  of  the  stenosis 
of  the  cervical  canal  by  angulation,  and  to  the  hypoplasia  of  the  genital 
organs.  If  operative  treatment  is  reciuired  it  should  usually  be  a  wide 
dilatation  of  the  cervical  canal,  which  will  compensate  for  the  stenosis  by 
angulation. 

The  two  operations  which  might  be  considered  are  the  Dudley  operation 
for  securing  a  liackward  displacement  of  the  external  os  and  the  straighten- 
ing of  the  cer\ical  canal,  or  the  operation  proposed  bj'  Reynolds  for  elongat- 
ing the  anterior  vaginal  vault.  I  have  tried  the  Dudley  operation,  but  do 
not  like  it.  It  leaves  a  deformed  and  distorted  cervix  and  I  have  been  able 
to  secure  better  results  in  this  condition  by  a  wide  and  permanent  dilatation 
of  the  cervical  canal. 

The  Reynolds  operation,  consisting  of  a  transverse  incision  in  the 
anterior  vaginal  vault  and  then  the  insertion  of  sutures  from  side  to  side 
in  such  a  manner  as  to  elongate  this  vault  might  be  valuable  if  the  anti- 
flexion itself  produced  symptoms — which  it  really  does  not.  This  operation 
cannot  be  expected  to  relieve  either  dysmenorrhoea  or  sterility. 

Prolap.se. — The  operative  treatment  of  prolapse  of  the  uterus  can  also 
be  dismissed  in  a  few  words.  There  are  few  cases  that  caiuKjt  be  perma- 
nently cured  l\v  a  combination  of  interposition  anteriorly  and  a  proper 
perineorrhaphy  and  repair  of  the  pelvic  floor  posteriorly,  combined  often 
with  an  amputation  of  the  cervix  if  there  is  elongation  of  the  supravaginal 
portion.  If  these  operations  are  done  properly  (page  70),  it  is  quite  possible 
to  make  the  exit  of  the  uterus  from  the  l)irth  canal  a  physical  impossibility. 

I  have  found  no  occasion,  therefore,  for  the  radical  procedures  recom- 
mended from  time  to  time  for  prolapsus  uteri,  such  as  vaginal  hysterectomy 
and  the  anchorage  of  the  vaginal  stump  to  the  abdominal  wall,  or  splitting 
the  uterus  and  burying  the  two  halves  in  the  anterior  abdominal  wall. 

Some  cases  may  possibly  require  such  radical  treatment,  but  not  for 
the  prolapsus  alone.  If  there  is  a  suspicion  of  malignancy  or  a  persistent 
metrorrhagia  in  a  middle-aged  woman,  I  find  an  operation  combining  the 
features  of  Goffe's  mmiber  2  and  the  Mayo  operation  most  satisfactory. 
The  uterus  is  completely  removed  by  the  vaginal  route  (page  217)  and  three 
stumps  of  the  broad  ligament  are  formed  by  ligatures  on  each  side.    These 


PROLAPSE  AND  INVERSION  OF  THE  UTERUS  119 

stumps  are  united  in  the  middle  line  and  by  the  same  stitch  are  fastened 
to  the  fascia  directly  beneath  the  anterior  vaginal  wall,  thus  interposing 
these  stumps  between  the  bladder  and  the  vagina. 

Inversion. — Fortunately  we  possess  an  operative  treatment  for  inver- 
sion of  the  uterus  which  can  always  be  depended  on  unless  inversion  has 
been  associated  with  some  degenerative  process  of  the  uterine  body,  such 
as  partial  or  total  necrosis,  demanding  the  removal  of  the  womb. 

The  proper  time  to  treat  inversion  of  the  uterus  is  immediately  after 
its  occurrence.  If  the  physician  understands  the  proper  method  of  taxis, 
there  ought  never  to  be  much  difficulty  in  replacing  an  inverted  womb. 
I  have  been  aisle  to  do  this  in  at  least  six  cases.  The  latest  one  was  five 
days  after  the  woman's  delivery.  After  that  time  the  replacement  becomes 
difficult  or  impossible,  and  operative  treatment  is  demanded. 

In  the  Spinelli  operation  we  have  a  procedure  that  can  always  be 
depended  upon  but  it  is  well  to  remember  that  the  operation  need  not  always 
be  as  extensive  as  Spinelli  recommended.  (Plate  LXXIV-LXXIX.)  In 
two  out  of  four  of  these  operations  which  I  have  performed,  I  was  able  to 
replace  the  uterus  without  opening  the  peritoneal  cavity.  In  undertaking 
the  operation,  therefore,  this  possibility  should  always  be  borne  in  mind. 
After  opening  the  anterior  vaginal  vault  by  a  transverse  incision  and  then 
by  a  blunt  dissection  separating  the  tissues  up  to  the  reduiilication  of  the 
peritoneum,  the  anterior  lip  of  the  cervix  and  the  lower  uterine  segment 
should  be  severed  as  shown  in  the  illustration.  An  attempt  should  then 
be  made  to  replace  the  uterus  before  proceeding  further.  This  can  best  be 
done  by  beginning  the  upward  pressure  against  the  inverted  body  of  the 
womb  at  the  upper  angle  of  the  wound  in  the  cervix  and  in  the  lower  uterine 
segment.  If  this  attempt  fails  after  a  justifiable  application  of  force  and 
after  the  lapse  of  some  little  time,  in  the  attempt,  the  peritoneal  cavity 
must  then  be  opened  and  the  incision  extended  into  the  uterine  body  by 
reversing  the  direction  of  the  scissors;  but,  at  each  extension  of  the  incision, 
an  attempt  to  rein  vert  the  womb  should  be  made.  It  may  be  necessary  to 
slit  practically  the  whole  anterior  surface  of  the  uterus  in  two,  but  it  may 
easily  be  possible  to  reinvert  the  uterus  without  such  an  extensive  wound. 
It  is  obviously  an  advantage  to  avoid  a  scar  running  the  whole  length  of  the 
uterus  if  the  woman  is  ever  to  become  pregnant  again.  After  the  reinversion 
of  the  uterus  is  accomplished,  the  uterine  wound  is  closed  by  a  two-tier 
catgut  suture  in  the  myometrium  and  then  by  a  continuous  up-and-down 
lace  suture  in  the  perimetrium.  The  opening  in  the  peritoneal  ca\ity  is 
then  closed  and  the  vaginal  A-ault  united  by  interrupted  sutures.  Drainage 
is  not  required. 


PLATE   !>XX!V. 


Spinelli  operation  for  inversion  of  uterus.  Transverse  incision  of  vagina  over  the  cervix. 


PLATE  LXXV. 


T-shaped  incision  to  gain  more  room. 


PLATE  LXXVI. 


Discission  of  a  ring  muscle  in  cervix  begun. 


PLATE  LXXVII. 


If  necessary  discission  of  uterine  wall. 


PLATE  I.XXVIII. 


Uterus  re-inverted  and  wound  in  the  wall  closed. 


PLATE  LXXIX. 


Mucous  membrane  united. 


126  ATLAS  OF  Ol'KRATIVE  GYN^X'OIXK.Y 

DILATATION  OF  THE  CERVICAL  CANAL 

Dilatation  of  tlie  cervical  canal  can  he  effected  by  instrumental  dila- 
tation, liy  the  insertion  of  an  intra-nterine  stem  which  is  retained  in  place 
for  a  mniilici-  of  weeks;  by  an  anterior  vaginal  hysterotomy;  by  electrolysis; 
and,  in  the  case  of  a  pregnant  uterus,  liy  rubber  bags  distended  with  water. 

Instrumental. — If  the  dilatation  is  jierfornied  upon  the  non-pregnant 
uterus,  my  practice  is  to  use  three  instrumental  dilators  in  succession :  the 
weaker  model  of  the  Goodell  dilator  modified  by  Bacr;  the  stronger  two- 
branch  dilator  devised  by  Wathen  of  L()uis\iUe  and  last  the  four-branch 
dilator  named  after  Dr.  Cleveland  of  New  York  City.  Following  this  I 
insert  my  own  modification  of  8chatz's  metranoicter  which  I  have  now  used 
for  some  eight  or  nine  years  with  great  satisfaction.  It  effects  a  wide  dila- 
tation of  the  cervical  canal  if  left  in  place  for  twenty-four  hours.  If  the 
widest  possible  dilatation  is  desired,  it  can  be  replaced  in  twenty-four 
hours  by  a  fresh  instrument,  which  is  allowed  to  remain  in  place  twenty- 
four  hours  more.  When  the  instrument  is  removed  the  uterus  is  washed 
out  with  Lugol's  solution,  one  drachm  to  the  i)int. 

Perfornu'd  for  sterility,  this  instrument  has  given  me  a  forty-three 
per  cent,  cure  in  the  patients  from  whom  I  have  secured  an  answer  more 
than  two  years  after  the  operation  was  performed.  One  of  my  staff  ad- 
dressed one  hundred  and  sixty-seven  letters  to  these  patients  some  years 
ago,  and  from  the  replies  received  was  able  to  record  a  forty-three  per  cent, 
cure;  and  that  without  a  prior  examination  of  the  husbantl,  which  I  now 
insist  upon  before  undertaking  an  oi)erati()n  for  sterility. 

For  mechanical  dysmenorrhoea,  this  form  of  dilatation  is  not  so  suc- 
cessful; it  gives  temporary  but,  in  the  majority  of  cases,  not  jiermanent 
relief.  I  tried  the  intra-uterine  tube  designed  by  Wylie  of  New  York,  the 
successor  of  the  old  intra-uterine  stem,  and  its  various  modifications  for  a 
period  of  two  years,  but  was  obliged  to  give  it  up  on  account  of  the  percent- 
age of  infected  tubes  and  endometrium  which  result  from  its  use.  There 
is  no  way  of  escaping  this  disadvantage.  Any  foreign  body  left  in  the 
uterus  for  a  considerable  space  of  time  is  certain  to  result,  occasionally,  in 
an  infection ;  and  I  am  now  seeing  cases  of  this  sort  in  which  my  colleagues 
still  use  this  implement,  so  that  my  belief  in  its  danger  is  confirmed.  In 
some  cases,  Hcgar's  graduated  bougies  will  be  found  a  useful  instrimient 
for  the  dilatation  of  the  cer\'ix.  I  find  the  chief  use  of  this  instrument  to  be 
after  a  contraction  of  the  cervix  fallowing  the  more  radical  instrumental 
dilatation  just  described.  Hegar's  bougies  are  also  useful  if  it  is  desired  to 
dilate  the  cervix  prior  to  the  use  of  the  uterine  endoscope  to  avoid  obscuring 
the  field  of  vision  by  blood.  The  large  sizes  of  the  Hegar's  dilators  for  the 
pregnant  uterus  are  occasionally  useful  in  multijjarse,  but  are  not  so  good 
as  rubber  bags. 


DILATATION  OF  THE  CERVICAL  CANAL  1-27 

For  the  pregnant  uterus,  there  is  a  useful  two-branch  dilator  modified 
from  the  original  instrument  of  Gau  by  J.  C.  Hirst.  This  instrument  secures 
a  dilatation  of  the  pregnant  cervix  to  the  extent  of  seven  centimetres  in  a 
linear  direction.  This  degree  of  dilatation  is  safe.  A  more  powerful  dilator 
for  the  pregnant  cervix  is  a  four-branched  instrument  such  as  the  Bossi  and 
its  modifications,  a  very  good  one  being  the  instrument  devised  by  the  late 
Dr.  Dewees.  They  are  not  so  generally  used,  however,  as  thej^  were  for  a 
time  after  Leopold  of  Dresden  called  the  attention  of  gyna-cologists  to 
Bossi's  dilator.  These  instrumental  dilators  are  too  powerful  and  too  likely 
to  inflict  serious  damage  upon  the  cervix.  If  used  at  all  the  dilatation  should 
never  be  carried  to  a  diameter  of  more  than  four  centimetres.  For  the  con- 
tinuance of  the  dilatation  of  the  pregnant  cer\ix  and  its  extension,  rubber 
bags  are  used.  After  trying  all  the  models  de\ased,  I  had  one  made  which 
I  think  is  superior  to  the  conical  bags  in  general  use.  The  disadvantage 
of  these  conical  bags  is  that  they  elongate  the  cervix  and  are  apt  to  dis- 
place the  presenting  part.  By  pulling  upon  them,  as  is  often  recommended 
to  hasten  the  dilatation,  a  prolapsus  uteri  often  results.  The  flattened 
hour-glass  shape  of  my  bags  avoids  all  these  disadvantages;  they  are  more 
difficult  to  insert  accuratelj',  but  once  put  in  proper  position  they  effect  a 
dilatation  of  the  cervix  more  satisfactorily  and  with  less  disadvantage  than 
any  model  that  I  have  ever  tried. 

Anterior  Y.\gix.\l  Hysterotomy. — This  is  an  extremelj-  valuable 
procedure  for  the  exploration  and  evacuation  of  the  uterine  cavity.  (Plate 
LXXX-LXXXV.)  It  may  be  utilized  for  the  digital  exploration  of  the 
uterine  cavitj',  for  the  removal  of  polypoid  and  submucous  tumors,  and  for 
the  evacuation  of  the  pregnant  uterus  up  to  the  seventh  month.  Beyond 
that  time  the  fetal  head  is  so  large  that  the  incision  in  the  anterior  uterine 
wall  may  be  dangerously  extended  and  may  possibly  involve  injury  to  tl:e 
bladder,  even  if  the  posterior  lip  is  also  cut  to  gain  more  room. 

The  anterior  lip  of  the  cervix  is  seized  bj'  two  double  tenacula;  and  after 
making  a  T-shaped  incision  in  the  anterior  vaginal  wall  and  dissecting  the 
flap  backward,  and  by  a  blunt  dissection  with  a  piece  of  gauze  separating 
the  bladder  from  the  cervix,  the  latter  up  to  and  beyond  the  internal  os  is 
cut  with  scissors  directly  in  the  middle  line,  the  incision  beginning  between 
the  two  tenacula.  It  may  occasionally  be  necessary  to  cut  the  uterovesical 
ligament  and  to  separate  completely  the  bladder  from  the  uterus;  but 
ordinarily  such  a  high  dissection  is  not  required.  Before  making  the  incision 
in  the  cervix  and  lower  uterine  segment,  the  bladder  is  protected  by  an 
anterior  vaginal  retractor. 

In  suturing  the  uterine  wound,  a  number  three  strand  of  chromic  catgut 
and  a  curved  needle  are  recjuired.  It  is  advisable  not  to  put  the  fu'st  suture 
in  the  upper  angle  of  the  wound  but  rather  about  midway  up ;  and  this  suture 


128  ATLAS  OF  OPERATIVE  GYN.ECOLOCIY 

can  be  used  as  a  tractor  to  bring  into  view  the  upper  portion  of  the  wound. 
Interrupted  sutures  are  then  inserted  up  to  the  upper  angle,  care  being  taken 
not  to  close  the  cervical  canal  which  is  protected  bj'  an  instrument  such  as 
a  uterine  two-way  catheter  placed  within  the  canal.  As  the  sutures  are 
placed  in  the  lower  portion  of  the  wound,  they  are  inserted  from  side  to 
side  until  the  end  of  the  wound  in  the  cervix  is  reached;  when  two  sutures 
are  inserted  at  right  angles  to  the  othei's.  In  this  way  the  cleft  in  the  cervix 
which  often  follows  this  operation  may  be  a\-oided.  The  wound  in  the 
cervix  being  closed  in  this  manner,  the  vaginal  flaps  are  brought  together 
and  united  to  the  cervix  by  interrupted  sutures  of  number  1  chromic  catgut. 
Electrolysis. — In  ill-de\eloped  uteri  the  contraction  of  the  cervical 
canal  after  an  instrumental  tlilatation  can  be  pre\ented  by  electrolysis.  It 
procures  also  a  wider  dilatation  than  could  otherwise  be  obtained.  This 
treatment  has  the  additional  advantage  of  securing  a  development  of  the 
uterus,  and  is  the  only  agent  which  can  accomplish  this  purpose.  I  have 
had  a  number  of  cases  of  sterility  associated  with  infantile  uteri  in  which 
electrical  stimulation  secured  a  development  of  the  uterus  vuitil  a  full 
internal  measurement  was  obtained,  followed  by  impregnation  and  deli\'ery 
at  term.  This  treatment  is  carried  out  by  the  insertion  into  the  uterine 
cavity  of  a  copper  electrode,  as  a  negative  pole,  while  a  positive  pole  con- 
sists of  a  large  sponge  placed  upon  the  woman's  abdomen.  A  galvanic 
current  of  from  nine  to  twelve  milliamperes  is  applied  to  the  uterine  cavity 
for  about  ten  to  fifteen  minutes  every  other  day  for  a  jieriod  of  four  to  six 
weeks.  If,  in  addition  to  the  enlargement  of  the  cervical  canal,  it  is  desired 
to  procure  a  further  development  of  the  uterus,  two  faradic  currents  (the 
rapid  and  slow  interrupted),  and  the  sinusoidal  current  are  employed  in 
addition,  the  whole  treatment  continuing  for  about  twenty  minutes. 


PLATE  LXXX. 


\'aginal  incision  for  anterior  vaginal  hysterotomy. 


PI, ATI-:   I.XXXI. 


Pushing  up  bladder  with  gauze  pad. 


PLATK  LXXXII. 


Incising  cervix  and  lower  uterine  segment. 


PLATE  LXXXIII. 


InciBion  completed,  exposing  pouting  membranes. 


PLATE   LXXXIV. 


Sutures  of  uterine  and  cervical  wounds. 


PI.ATK    T.XXXV. 


Vaginal  flaps  closerl. 


ENLARGING  THE  VAGINAL  INTROITUS  135 

AN  OPERATION  FOR  ENLARGING  THE  VAGINAL  INTROITUS  IN 

CASES  OF  VAGINISMUS 

In  neurotic  women  a  spasmodic  contraction  of  the  muscles  around  the 
entrance  to  the  vagina  is  not  at  all  rare.  The  levator  ani  and  the  constrictor 
vagintp  are  the  muscles  involved.  L^sually  the  physician  sees  a  patient  with 
this  condition  some  time  after  marriage,  as  embarrassment  prevents  her 
from  seeking  immediate  medical  aid.  I  have  had  women  under  my  care 
who  have  had  no  marital  relations  for  thirteen  and  twenty  j-ears  on  this 
account,  and  a  number  of  others  with  a  history  of  a  shorter  duration  of 
the  dyspareunia.  It  is  possible  to  cure  the  cases  of  a  minor  grade  by  gradual 
dilatation  with  the  large-sized  graduated  Hegar  dilators  made  for  the  preg- 
nant uterus;  these  are  given  to  the  woman  with  instructions  to  use  them 
gently  and  carefully  after  warming  and  oiling  them,  and  to  allow  herself 
plenty  of  time  to  effect  the  desired  degree  of  dilatation.  The  period  usually 
required  is  on  an  average  six  weeks. 

If  this  treatment  fails,  or  in  the  more  exaggerated  cases  in  which 
gradual  dilatation  cannot  be  endured,  an  operation  is  indicated;  this 
involves  cutting  the  levator  ani  in  each  posterior  vaginal  sulcus,  imitating 
the  lacerations  of  the  genital  canal  in  childbirth.  (Plates  LXXXM- 
LXXXVII.)  The  incision  goes  through  both  layers  of  the  triangular  liga- 
ment, separates  a  sufficient  extent  of  the  muscle  to  allow  the  insertion  of 
three  fingers  in  the  ^■agina,  and  is  extended  to  a  moderate  degree  downward 
in  the  middle  line  of  the  perineum  through  the  perineal  body.  The  mucous 
membrane  is  then  united  as  shown  in  Plate  LXXXVIII.  Packing  is  placed 
in  the  vagina  and  left  undisturbed  for  two  daj's.  It  is  not  necessary  to 
repack.  I  have  not  yet  known  this  operation  to  fail.  In  the  two  cases 
quoted,  one  of  thirteen  and  one  of  twenty  years'  duration,  there  was  an 
immediate  success.  I  have  also  cured  a  number  of  cases  of  sterility  from 
this  cause  and  from  a  long  experience  ^\-ith  the  operation  I  have  acquired 
great  confidence  in  it. 

Attempts  at  marital  relations  must  be  postponed  until  perfect  healing 
of  the  wound  is  .secured,  and  then  the  husband  must  be  cautioned  against 
any  roughness  or  violence  which  might  hurt  or  frighten  the  patient. 


PI.ATK  T. XXXVI 


First  incision  for  vaginismua  operation. 


PLATE  LXXXVII. 


Second  incision  for  vaginismus  operation. 


PLATK  LXXXVIII. 


Incision  through  levators  and  triangular  ligament. 


PLATE   LXXXIX 


Uniting  mucous  membrane  over  incisions  so  as  to  let  the  cut  muscles  gap  apart. 


10 


140      .  ATLAS  OF  OPERATRE  GYN.ECOLOC.Y 

OPERATIONS  FOR  GYNATRESIA 

These  operations  \ary  in  degree  from  the  l)hnit  dissection  separating 
the  agglutinated  labia  of  a  new-born  female  infant  to  the  construction  of  an 
artificial  vagina. 

The  interniediate  operations  are  dissections,  sometimes  blunt,  but 
usually  l)loody,  of  transverse  septa  varying  in  situation  and  in  depth, 
perhaps  including  the  whole  or  the  greater  part  t)f  the  length  of  the  vagina; 
or,  as  is  usually  the  case,  consisting  of  transverse  septa  no  thicker  than  the 
ordinary  hj'men.     (Plate  XC.) 

If  the  atresia  affects  only  the  lower  i)ortion  of  the  genital  canal,  while 
the  upper  portion  is  fairly  well  developed,  menstruation  occurs  without  the 
escape  of  blood  externally;  the  consequence  is  an  accumulation  of  blood 
within  the  uterus — htcnuitometra,  or  in  the  tube — htrmatosalpinx.  It  is 
the  latter  possibility  which  makes  such  cases  serious.  While  it  is  usually 
easy  enough  to  reach,  to  e\-acuate,  and  to  wash  out  with  a  boracic  acid 
solution  the  accumulation  of  blood  in  the  uterus,  it  is  impossible  to  reach 
the  collection  within  the  tubes,  which  cannot  possibly  drain  themselves 
although  there  is  enough  of  a  communication  left  between  tubes  and  uterine 
cavity  to  insure  a  rapid  infection  of  the  accumulated  blood  in  the  former. 
It  is  a  disputed  point  how  the  abdominal  orifices  come  to  be  closed  in  these 
cases;  the  irritation  of  a  foreign  body — blood — oozing  from  the  tubes 
causes,  I  believe,  an  inflammation  of  the  peritoneum  and  an  agglutination 
of  the  fimbria-. 

Therefore  a  jiart  of  e\'ery  operation  to  evacuate  retained  blood  in  the 
genital  tract,  in  consequence  of  gynatresia,  is  an  exploratory  abdominal 
section  to  inspect  the  tubes.  If  they  are  found  cUstended  they  should  be 
removed  and  the  cornua  should  be  carefully  closed  by  sutures.  It  is  then 
safe  to  dissect  the  closed  vaginal  canal,  and  if  necessary  the  cervix,  in  order 
to  reach  the  accumulation  of  blood  in  the  uterus;  which  is  evacuated  and 
washed  jiersistently  with  a  boracic  aciil  solution  imtil  the  cavity  is  com- 
pletely emptied.  If  there  has  been  an  infection  of  the  uterine  contents 
before  the  operation,  and  there  is  pus  in  the  uterine  cavity  instead  of  blood, 
a  hysterectomy  must  be  considered  with  a  complete  removal  not  only  of 
uterus  but  of  tubes  also. 

A  pyometra  will  more  often  be  found  in  connection  with  an  acquired 
atresia  of  the  lower  genital  canal.  I  have  seen  such  a  condition  in  connection 
with  a  vesicovaginal  fistula  above  the  point  of  atresia,  and  I  have  been 
obliged  to  operate  on  such  a  case  in  which  the  vagina  was  deliberately 
closed  by  a  former  operator  in  order  to  correct  a  vesicovaginal  fistula 
which  it  had  been  impossible,  apparently,  to  close  by  the  usual  operation. 
Hysterectomy  must  also  be  considered  in  cases  of  ill-development  of  the 
uterus  with  closure  of  the  vagina.    I  once  operated  on  an  interesting  case 


OPERATIONS  FOR  G^'NATRESU 


Ul 


of  this  sort  in  whicli  there  was  a  large  hsematoinetra  and  an  enormous 
hsematosalpinx  in  a  uterus  unicornus  and  a  single  tube.  In  complete  gyna- 
tresia involving  an  absence  of  the  vagina  and  also  of  the  uterus,  represented 
only  by  a  small  bundle  of  muscle  fibre  without  a  trace  of  uterine  cavity, 
it  is  sometimes  necessary  to  consider  the  remo\al  of  the  o\aries,  as  patients 
with  this  condition  have  se\ere  menstrual  molimina  unrelieved  by  the 
periodic  loss  of  blood  in  a   menstruation. 


Fig.  21. — Congenital  absence  of  the  vagina. 


If  the  genital  canal  is  preserved  above  the  site  of  the  atresia,  the  vaginal 
canal  can  be  preserved  by  uniting  the  mucous  membrane,  below  the  point 
of  occlusion,  to  the  mucous  membrane  above  that  point.  The  raw  area 
left  by  the  dissection  of  this  area  is  thus  covered  by  mucous  membrane 
(Plate  XCI)  and  a  patent  continuous  vaginal  canal  is  secured.  If  there  is 
an  entire  absence  of  the  vagina,  but  a  uterus,  uterine  cavity,  and  cervix, 
flaps  of  skin  may  be  turned  in  from  the  labia  or  from  the  external  genitalia 
and  united  to  the  cervix.    This  sort  of  artificial  \agina  it  is  possible  to  keep 


PLATE  XC. 


Crucial  incision  for  imperforate  hymen  or  transverse  vaginal  septum. 


PLATE  XCI. 


R:iw  surfuiTs  roverecl  by  ihucmus  meiiibrnne  altpr  iniisi.jii  uf  imperforate  hyiuen  or  transverse  vaginal  septum. 


(J 


J 

». 


PLATE  XCIII. 


Lateral  anastomosis  of  ileum  and  pulling  the  isolated  portion  of  intestine  into  the  artificial  vaginal 
canal  made  by  blunt  dissection. 


PLATE    XCIV. 


Segment  of  intestine  sutured  into  the  artificially  made  vaginal  canal. 


PLATE  XCV. 


Point  of  reduplication  in  intestinal  segment  opened  so  as  to  establish  a  canal  lined  by  mucous  membrane. 


I'r,ATE   XCVI. 


Septum  between  apposed  intestinal  loops  removed. 


AN  OPERATION  FOR  ANUS  VESTIBULARIS  149 

open,  perhaps  with  the  aid  of  Sims's  plug  of  glass  or  haid  ruljljcr,  or  pos- 
sibly by  gauze  packing  contained  within  a  thin  rubber  pouch  (condom). 
But  even  then,  and  even  if  the  atresia  is  limited  to  a  small  area,  precaution 
must  be  taken  to  prevent  a  cicatricial  contraction  at  the  site  of  the  atresia. 
If  there  is  an  absence  of  the  whole  genital  tract,  with  the  exception  perhaps 
of  the  tubes  and  ovaries,  the  question  of  making  an  artificial  vagina  for 
purposes  of  coition  must  occasionally  be  considered.  As  a  rule  the  propriety 
of  this  o)ieration  is  questionable,  but  occasionally  it  is  justifiable— as  in  a 
case  recently  under  my  care  where  coition  was  accomplished  through  the 
urethra  without  present  incontinence  but  with  imminent  danger  of  it  and 
with  the  constant  possibility  of  a  severe  cystitis.  E\-en  in  such  a  case,  it 
might  be  preferable  to  avoid  the  only  operation  practicable  for  making  an 
artificial  vagina,  and  to  allow  marital  relations  to  be  continued  in  the  ab- 
normal manner  in  wliich  they  had  been  begun.  The  question  should  cer- 
tainly l)e  ])ut  jilainly  Ijefore  both  husband  and  wife  as  to  whether  a  major 
operation  in\olving  some  risk  to  life  shouUl  be  undertaken  for  the  sole 
purpose  that  it  could  attain.  If  an  operation  for  an  artificial  vagina  is 
decided  upon,  there  is  no  question  that  the  only  one  which  promises  a  per- 
manent success  is  the  operation  devised  by  Baldwin  with  utilization  of  the 
intestinal  tract  as  illustrated  in  Plates  XCII-XCVI.  I  ha^•e  used  all  the 
plastic  operations  for  an  artificial  vagina,  including  the  implantation  of  one 
woman's  vagina  in  another;  but  they  all  failed  eventually.  I  have  seen  an 
artificial  vagina  constructed  from  a  segment  of  the  rectum  through  an 
incision  alongside  the  sacrum,  which  was  partially  removed  as  in  a  Kraske 
operation ;  and  I  have  attempted  such  an  operation  myself.  But  the  tech- 
nical difficulty  was  so  great  and  the  patient's  condition  became  so  bad  that 
I  gave  it  up  without  completing  it.  I  should  select  the  operation  which 
utilizes  a  section  of  the  small  intestine,  if  I  ever  undertook  such  a  thing  at 
all;  but  as  yet  I  ha\'e  not  seen  a  case  (out  of  a  considerable  number  of  cases 
of  absence  of  the  genital  canal  under  my  care)  in  which  such  a  jirocedure 
seemed  to  me  justifiable. 

AN  OPERATION  FOR  ANUS  VESTIBULARIS 

.\n  interesting  congenital  anomaly  re([uiring  surgical  treatment  is  the 
opening  of  the  anus  into  the  fossa  navicularis,  usually  described  as  anus 
vestibularis,  although  the  fossa  navicularis  is  not,  strictly  speaking,  a  part 
of  the  vestibule.    (Plates  XCVII-XCIX.) 

I  have  operated  on  this  condition  twice  with  success,  once  in  an  infant 
a  year  old  and  once  in  a  girl  aged  sixteen. 

The  sphincter  and  lower  rectum  are  dissected  loose,  anteriorly  and  to 
a  certain  tlegree  laterally,  after  making  a  longitudinal  incision  from  the 
posterior  edge  of  the  anus  to  the  point  on  the  perineum  where  the  anus  is 


PLATE  IXCVIl. 


Anus  vestibularis. 


PLATE   XCVIII. 


Anus  vestibularis  dissected  loose  and  an  incision  below  it  preparatory  to  its  fixation  in  a  normal  posiUon. 


PLATE  XCIX. 


Anus  vestibularis  transferred  to  normal  position  and'fixed  there. 


OPERATIONS  ON  THE  VULVA  153 

normally  situated.  The  anus,  sphincter  muscle,  and  a  small  segment  of  the 
rectum  are  then  pulled  back  to  the  posterior  termination  of  the  longitudinal 
incision  and  stitched  there  with  linen  thread.  The  longitudinal  incision  is 
then  closed  in  front  of  the  bowel. 

OPERATIONS  ON  THE  VULVA 

Operations  on  the  vulva  consist  of  the  removal  of  tumors,  cystic  or 
solid,  from  the  labia  majora  or  the  labia  minora;  the  removal  of  cy.'^ts  of  the 
vul\-o\-aginal  gland;  the  removal  of  venereal  warts,  and  operations  more 
or  less  extensive  on  the  external  genitalia  varying  from  the  removal  of  small 
adenocarcinomata  in  Skene's  glands  in  the  urethra  to  the  amputation  of 
the  labia  and  the  extension  of  the  incision  into  the  groins  for  the  removal 
of  the  lymphatic  glands  in  that  region. 

If  it  is  necessary  to  remove  large  cy.stic  or  solid  tumors  from  the  vulva, 
the  hemorrhage  may  prove  embarrassing;  as  a  rule,  however,  the  operator 
is  not  much  troubled  on  this  account,  as  the  ve.ssels  are  easily  accessible. 

ExsECTioN  OF  Vulvar  Nerves. — The  most  difficult  operation  in  this 
region  is  the  exsection  of  the  five  pairs  of  vulvar  nerves  for  pruritis  ^•ulv£e 
or  nymphomania.  I  have  done  five  of  these  operations  with  success,  but 
the  dissection  required  is  extremely  difficult  and  tedious. 

The  most  important  thing  to  remember  is  in  the  exsection  of  the  ter- 
minal division  of  the  pudic  nerve  into  the  perineal  nerve  and  the  nerve  of  the 
dorsum  of  the  clitoris.  If  the  exsection  of  the  pudic  nerve  is  made  below 
the  origin  f)f  the  nerve  which  controls  the  action  of  the  sphincter  ani. 
the  latter  may  be  severed,  with  permanent  incontinence  of  gas  and  faces 
as  a  result. 

Dissection  of  the  Inguinal  Canal  for  the  Removal  of  Fibroid 
Tumors  of  the  Round  Ligament. — It  is  convenient  to  include  this  among 
operations  on  the  vulva.  I  have  removed  three  of  these  growths,  each  of 
considerable  size.  The  operation  is  easy:  the  skin,  .'superficial  fascia,  fat, 
and  fascia  of  the  external  obliquus  are  incised  over  the  tumor,  which  is 
then  enucleated.  The  rest  of  the  operation  is  like  an  extensive  herniorrhaphy. 

Closure  of  the  Inguinal  Canal  for  Hernia. — In  the  female  this 
procedure  presents  some  features  differing  from  those  characterizing  the 
same  operation  in  the  male.  The  round  ligament  in  the  female  is  utilized 
in  the  closure  of  the  canal  and  there  is.  of  course,  no  vas  deferens  to  avoid. 

The  internal  ring  should  be  closed  with  permanent  sutures  of  linen 
thread  in  addition  to  the  obUteration  of  the  canal,  thus  making  the  perma- 
nent success  of  the  operation  more  certain. 

Procedure  hi  Pregnancy. — The  question  sometimes  arises  as  to  the 
propriety  of  removing  growths  of  the  vulva  in  pregnant  women.  This 
appUes  particularly  to  large  cysts  and  sohd  tumors  of  the  labia;  to  elephan- 


lot  ATLAS  OF  OPERATIVE  GYN-I^.COLOGY 

tiasis,  and  to  veueroal  warts  upon  the  external  genitalia.  The  coninion- 
sense  rule  to  follow  is  to  jiostpone  the  operation  until  after  deli\ery  or,  if 
the  bulk  of  the  tumors  constitutes  an  obstacle  to  delivery,  to  attempt  no 
operation  in  this  region  until  shortly  before  term,  allowing  if  ])ossil)le  two 
weeks  for  the  healing  of  the  wound  before  tlic  actual  onset  of  labor. 

Removal  of  the  Vulvovagin.\l  ok  Bartholin's  (Jland. — The 
commonest  operation  on  the  vulva  is  the  removal  of  a  distended  and  prob- 
ably suppurating  vulvovaginal  gland,  usually  but  not  always  the  result 
of  gonorrhoeal  infection.  If  not  removed  entire,  the  abscess  in  the  gland 
will  probably  recur  from  time  to  time.  The  incision  is  made  on  the  inner 
surface  of  the  labium  majus,  the  whole  length  of  the  tlistended  gland;  the 
gland  is  dissected  out  with  sharp-pointed  scissors  cur\ed  on  the  fiat;  care 
must  be  taken  not  to  incise  the  capsule  of  the  gland,  as  it  will  collapse  and 
its  removal  is  then  difficult;  this  is  certain  to  occur  when  the  efferent  duct 
is  cut,  but  by  that  time  the  dissection  should  be  complete.  If  the  abscess 
opens  spontaneously  just  before  the  operation,  or  is  prematurely  evacuated 
before  the  dissection  is  completed,  the  cavity  of  the  gland  may  be  filled 
with  sterile  paraffin  melting  at  110°  F.  which  is  usually  supplied  to  the 
nose  and  throat  specialists. 

The  space  left  after  the  removal  of  the  gland  is  closed  with  two  layers 
of  catgut  sutures,  a  horse-hair  drain  of  a  few  strands  of  silkworm  gut  being 
laid  in  the  deepest  jiortion  of  the  wound  and  emerging  from  Ijoth  extremities 
of  the  skin  incision. 

OPERATIONS  FOR  HERMAPHRODITISM 

It  is  a  safe  rule  in  all  cases  of  pseudohermaphroditism  in  which  the 
sex  is  really  doubtful  to  bring  up  the  individual  as  a  male.  This  course 
avoids  some  of  the  curious  and  awkward  situations  that  arc  often  noted  in 
such  cases. 

I  have  seen  an  indi\idual  married  for  twelve  years  as  a  wife,  who 
applied  for  a  diagnosis  of  the  cause  and  for  the  treatment  of  sterility,  but 
on  examination  was  foinid  to  be  a  male  pseudohermaphrodite.  I  have 
recently  examined  an  individual  about  seventeen  years  of  age  who  was 
acting  as  a  ladies'  maid,  and  applied  for  treatment  on  account  of  the  non- 
appearance of  menstruation.    This  individual  was  found  to  be  a  male. 

I  once  saw  a  man  nineteen  years  of  age  don  his  first  pair  of  trousers 
and  take  his  position  in  the  world  as  a  male.  He  had  been  brought  up  as  a 
woman  until  his  gruff  voice,  manly  stride,  and  sprouting  beard  aroused  a 
suspicion  as  to  his  true  sex.  On  the  contrary  I  had  the  opportunity  of 
examining  a  female  pseudohermaphrodite  brought  up  as  a  male,  perfectly 
happy  in  that  capacity,  keeping  a  small  cigar  shop  and  living  in  all  respects 
the  life  of  a  young  man.    Many  other  cases  of  this  kind  are  collected  in  that 


OPERATION  FOR  HERMAPHRODITISM  155 

extraordinary  book  on  licrmaphnxlitism  by  v.  Neugebauer.  Ono  occasion- 
ally sees  a  male  hermaphrodite,  however,  who  is  exceedingly  unhappy  as  a 
male.  All  the  secondary  external  characteristics  of  sex  in  such  individuals 
are  frecjuently  feminine  and  the  tastes  and  inclinations  are  all  those  of  a 
woman.  Consequently  these  creatures  are  miserably  unhappy  in  their  life 
as  males;  whereas,  if  they  hved  as  females,  they  would  be  moderately  con- 
tent and  would  not  ha\-e  that  marked  disposition  to  suicide  which  is  noted 
in  such  a  large  proportion  of  the  cases  collected  in  v.  Neugebauer's  book. 
I  have  examined  three  such  individuals  myself  and  in  two  of  them 
offered  to  renio\e  by  operation  the  characteristics  of  the  male  sex  and  to 
con\-ert  them  as  far  as  jiossible  into  females  by  enlarging  the  rudimentary 
\agina  and  by  tlie  removal  of  the  male  sexual  glands  and  the  penis.  Al- 
though these  creatures  applied  to  me  for  surgical  treatment,  none  of  them 
finally  accepted  it.  They  had  the  excessive  shjTiess  which  is  often  seen  in 
these  unfortunate  individuals  and  on  this  account,  I  think,  disappeared 
from  my  notice  after  making  arrangements  for  operative  treatment.  I 
should  not  hesitate,  in  a  case  of  this  kind,  to  perform  such  an  operation; 
for  I  am  convincefl  that  it  would  contribute  markedly  to  the  hai)j)iness  of  the 
hermaphrodite,  and  could  in  no  way  be  detrimental  to  the  indi\-idual  and 
probably  not  to  those  with  whom  he  came  in  contact. 


11 


PLATE  C. 


Incision  for  excision  of  labia  and  exposure  of  inguinal  glands. 


PLATE  CI. 


Suture  of  wound  after  removal  of  labia  and  inguinal  glands. 


158 


ATLAS  OF  OPERATIVE  GYNAECOLOGY 

SALPINGECTOMY 


Salpingectomy  is  indicated  for  jiyosalpinx,  hsematosaliiinx,  tuberculosis 
of  the  tubes  (Fig.  23),  streptococcic  infection,  carcinoma,  and  ectopic  ges- 
tation. In  hydnisal]Mnx  (Fig.  24)  I  i)refer  opening  the  fimbriated  extremity 
with  a  luemostat.  draining  the  tube,  and  preserving  it. 


Fig.   22. — Py()sali)iiix  or  pus  tube. 


m 


a:^-- 


Fig.  23, — Tuberculosis  nf  the  Fallopian  tube. 


SALPINGECTOMY 


15!) 


Operative  Procedure. — If  salpingectomy  is  indicated  the  method  of 
removing  the  tube  is  shown  in  Plates  CII-CV.  The  tube  is  first  cut  off 
from  the  uterine  cornu.  A  hsemostat  is  then  fastened  on  the  broad  ligament 
under  the  cut  extremity  of  the  tube:  another  is  clamped  on  the  free  edge  of 
tlie  broad  ligament  laterally,  securing  the  ovarian  artery.  The  tube  is  then 
cut  off,  traction  being  made  upon  it  with  the  hiemostat  fastened  to  its 
uterine  extremity;  as  the  middle  of  the  broad  ligament  is  reached  a  bleeding 
vessel  must  be  clamped.  The  broad  ligament  is  then  sewed  over  with  a 
lock  stitch  which  can  usually  be  dej^ended  on  to  check  the  hemorrhage  that 
would  otherwise  require  ligation  of  the  vessels  separately;  the  ends  of  the 
running  stitch  are  tied  around  the  free  edge  of  the  broad  ligament  securing 


Fig.  24. — Hydrosalpinx. 


the  ovarian  artery.  If  in  spite  of  this  stitch  there  should  be  some  oozing 
from  the  cut  surface  of  the  broad  ligament,  a  mattress  suture  maybe  em- 
ployed, under  the  ruiming  lock  stitch,  including  that  portion  of  the  broad 
ligament  from  which  the  hemorrhage  comes  (Plate  CVIII).  I  canietl  out 
this  practice  for  a  number  of  years  without  an  accident,  but  have  recently 
had  a  fatal  secondary  hemorrhage.  In  addition  to  the  lock  stitch,  therefore, 
I  now  tie  the  three  arteries  separately:  namely,  the  ovarian,  round  ligament, 
and  uterine.  If  it  is  intended  to  remove  the  tube  alone,  witliout  the  ovary, 
the  forceps  on  the  lateral  free  edge  of  the  broad  ligament  is  placed  abo\e  the 
ovary  and  includes  the  ovarian  fimbria  of  the  tube.  If  it  is  desired  to 
remove  the  ovary  also,  the  hsemostat  is  placed  below  the  o\ary.  I  prefer 
the  long  curved  Keen  hsemostat  for  this  purpose.  If  the  uterine  end  of  the 
tube  is  infiltrated  as  in  salpingitis  isthmia  nodosa,  the  proposition  of  Beuttner 


UiO  ATLAS  OF  OPERATIVE  GYN.ECOLOC.Y 

and  Polak  to  remove  the  fundus  uteri  with  the  interstitial  portions  of  the 
tube  is  an  excellent  pi'actice,  avoiding  irritation  and  uterine  leucorrhcea  in 
the  patient's  subsequent  life  history. 

An  interesting  ((uestion  arises  in  many  cases  of  salpingectomy  as  to 
the  remo\'al  of  both  tubes.  If  there  is  gonorrhoeal  infection,  and  only  one 
tube  seems  to  be  involved,  it  is  practically  certain  that  the  other  will  be- 
come infectetl  in  the  near  future.  I  always  examine  carefully,  therefore, 
to  see  if  there  is  even  a  drop  of  jnis  in  the  ajjparently  unaB'ected  tube;  and 
if  I  find  any  evidences  of  infection  at  all  both  tubes  are  remo\etl.  Even  if 
no  such  evidence  is  discovered,  it  is  usually  safer  to  remove  the  apparently 
healthy  tube,  unless  the  patient  or  her  husband  refuses  to  accept  the 
consequent  sterility. 

Ectopic  Gestation. — In  the  case  of  ectopic  gestation  the  proposition 
has  recently  been  advanced  for  the  removal  of  the  unaffected  tube  for  fear 
that  the  woman  will  have  an  ectopic  gestation  in  that  tube  in  the  future. 
But  this  would  seem  a  reprehensible  procedure,  usually  unnecessarily  steril- 
izing the  woman.  One  of  my  staff  collected  the  statistics  of  my  operations 
for  tubal  pregnancy  during  a  space  of  ten  years.  It  was  found  that  in  that 
time  I  had  operated  on  one  hundred  sixty-seven  tubal  gestations.  Of  this 
miml)er,  there  were  seven  who  lunl  a  repeated  gestation  sul)se(iuentl}'  in 
the  other  tube;  but,  from  the  reports  that  we  were  able  to  secure,  it  appeared 
that  thirty  children  had  been  born  subsequently  to  women  on  whom  I  had 
operated  for  ectopic  gestation.  This  seems  to  me  to  answer  conclusively 
the  question  as  to  whether  both  tubes  should  be  removed  in  this  condition. 
Had  I  followed  this  practice,  at  least  thirty  children  in  this  series  would  have 
l)een  deprived  of  the  ojiportunity  for  existence;  whereas  only  seven  of  the 
women  operated  upon  had  to  undergo  a  .second  operation  for  tubal  pregnancy. 

GoNORRHCEAL  INFECTION. — Another  important  practical  question  is 
whether  to  operate  immediately  in  an  acute  stage  of  suppurative  salpingitis 
which  may  usually  be  assumed  to  be  gonorrhoeal  in  origin. 

As  a  rule  it  is  better  to  wait  for  the  subsidence  of  the  acute  symptom, 
but  it  is  not  necessary  to  wait  an  inordinate  length  of  time.  I  find  that  four 
or  five  days  with  an  ice-bag  over  the  lower  abdomen  and  two  hot  douches 
in  the  vagina  daily,  with  care  to  secure  free  evacuation  of  the  bowels,  is 
usually  sufficient.  Some  operators  advocate  a  delay  of  weeks;  but  this,  in 
my  experience,  is  entirely  unnecessary,  and  I  do  not  hesitate  to  operate  at 
once  if  the  symptoms  are  very  threatening  and  I  fear  the  occurrence  of 
general  sujjpurative  peritonitis.  In  a  lunnber  of  cases  I  have  removed  tubes 
dripping  with  pus  from  the  fimbriated  extremities,  where  there  has  been 
no  time  for  closure  of  the  abdominal  orifices.  That  this  may  be  done  with 
impunity  is  demonstrated  by  the  fact  that  in  such  operations  there  has 
been  no  mortality  in  my  cases;  whereas  I  have  seen  fatal  general  suppurative 


SALPINGECTOMY  161 

peritonitis  from  hesitancy  to  operate  on  gonorrho'al  pus  tubes  in  an  acute 
stage  of  inflammation.  It  is  uncjuestionably  better  to  wait  for  the  subsidence 
of  acute  inflammation,  if  this  seems  practicable;  but  carrying  this  practice 
too  far  occasionally  results  in  a  mortality  that  might  have  been  avoided. 

Drainage. — Another  question,  and  one  difficult  sometimes  to  answer, 
is  whether  or  not  to  drain  the  pelvis  in  cases  of  acute  salpingitis.  In  strepto- 
coccic infection  of  the  tubes  which  results  in  an  interstitial  salpingitis  rather 
than  a  pyosalpinx,  drainage  as  a  rule  is  necessary.  In  gonorrhoeal  and  tuber- 
culosis pus  tubes,  drainage  is  rarely  required.  How  to  drain  is  another 
question  which  the  operator  must  be  prepared  to  answer — whether  to  drain 
the  pelvic  cavity  through  the  vaginal  vault,  or  through  the  abdominal 
incision.  I  ha\e  tried  both  forms  of  drainage  extensively,  and  am  now 
quite  clear  that  the  drainage  through  the  abdominal  wound  gives  the  least 
morbidity  and  mortality  following  operation. 

As  to  the  method  of  abdominal  drainage,  my  professional  career  has 
embraced  prevailing  methods  of  different  types,  so  that  my  experience 
enables  me  to  judge  of  their  various  merits.  At  first  nothing  but  a  glass 
tube  was  used.  This  was  subsecjuently  replaced  b.y  gauze  alone;  but  each 
had  its  disadvantages:  the  glass  tubes  did  not  protect  the  abdominal 
organs  from  contamination,  and  often  resulted  in  a  new  infection  after  the 
operation;  whereas  the  gauze  drainage  of  the  pelvis  did  not  always  drain 
material  which  accumulated  in  Douglas's  pouch.  I  had  the  opportunity 
in  some  post-mortem  examinations  to  find  a  quarter  of  a  pint  of  infected 
bloody  and  purulent  material  in  Douglas's  pouch  which  the  gauze  drainage 
had  not  disposed  of.  Since  then  I  have  adopted,  as  a  rule,  the  use  of  both 
glass  tube  and  gauze  packing,  and  my  results  have  materially  improved. 
Occasional  cases  are  better  treated  by  the  cigarette  drain  or  by  a  simple 
rubber  tube.  But  the  whole  question  of  drainage  will  be  discussed  in  a 
separate  section. 


PLATE  CII. 


Salpingectomy:  separation  of  tube  from  uterine  cnrnu. 


PLATE  cm. 


Tube  cut  away. 


PLATE  CIV. 


JWII     '    "IIIIIIHK   li. 


Haw  edge  of  broad  ligament  with  arteries  elaiiiped. 


PLATE  CV. 


Chain  stitrh  to  control  hemorrhage  terminating  by  ligating  the  ovarian  artery. 


PLATE  CVII. 


Salpingo-oophorectomy. 


PLATE  CVIII. 


Vessels  secured  by  chain  or  lock-stitch  closing  upper  edge  of  broad  ligament. 


OOPHORECTOMY  169 

OOPHORECTOMY 

The  removal  of  an  ovary  is  required  for  a  number  of  indications :  neo- 
plasms, infections,  chronic  and  acute  inflammations,  degeneration  and  adhe- 
sions. Occasionally  the  removal  of  healthy  ovaries  is  deinanded  but  only, 
in  my  experience,  in  those  cases  of  ill-development  of  the  rest  of  the  genital 
tract  in  which  the  menstrual  periods  are  accompanied  by  severe  menstrual 
molimina  which  are  not  relieved  by  the  periodic  loss  of  blood  and  conse- 
quent diminution  of  pelvic  congestion.  The  ovary  may  be  removed  entire 
or  only  in  part — in  the  latter  case  for  a  localized  neoplasm,  cyst,  inflannna- 
tion,  or  degeneration. 

The  technic  of  removal  of  the  entire  ovary  is  illustrated  in  Plates 
CIX,  ex.  If  the  mesovarium  is  very  broad,  three  instead  of  two  inter- 
lacing ligatures  may  be  required;  and  the  raw  surface  left,  after  ligation  of 
the  mesovarium,  may  with  advantage  be  sewed  over  by  a  running  stitch 
above  the  catgut  ligatures,  or  it  may  be  implanted  in  the  split  posterior 
layer  of  the  broad  ligament  which  is  then  sewed  over  it. 

In  the  removal  of  large  ovarian  cystic  tumors,  it  may  be  of  advantage 
to  puncture  the  cyst  and  thus  diminish  its  bulk,  thereby  reducing  the  length 
of  the  abdominal  incision;  but  there  are  quite  a  number  of  ovarian  cysts 
which  should  not  be  punctured  before  removal—for  example,  malignant 
tumors,  dermoid  cysts,  and  large  abscesses  of  the  ovaries. 

The  ordinary  simple  serous  cyst,  simple  glandular  cyst,  and  even  the 
pseudomucin  cyst  may  be  punctured  with  impunity  before  removal;  but 
in  the  latter  case,  if  any  ovarian  contents  have  spilled  into  the  pelvic  or 
abdominal  cavities,  care  should  be  taken  to  remove  them  for  fear  of  implan- 
tation metastases  and  the  subsequent  development  of  pseudomyxoma 
peritonei.  The  color  of  the  simple  serous  cyst,  the  simple  glandular  cyst, 
and  the  pseudomucin  cyst  indicates  as  a  rule  their  true  character,  the  first 
two  having  comparatively  thin  walls  and  showing  the  clear  fluid  contents 
through  them;  the  latter  ha\ing  a  characteristic  blue  color  well  described 
as  cerulean  blue.  If  the  operator  is  in  doubt  as  to  whether  an  ovarian  tumor 
should  be  punctured  or  not,  he  should  always  avoid  this  procedure  and 
should  make  an  abdominal  incision  of  sufficient  length  to  deliver  the  ovarian 
tumor  entire,  no  matter  how  long  this  incision  may  ha\e  to  Ije. 

If  one  ovary  is  the  site  of  a  neoplasm,  the  condition  of  the  other  ovary 
should  always  be  carefully  investigated;  for  a  large  proportion  of  ovarian 
tumors  is  bilateral;  so  that  if  there  is  any  indication  of  a  beginning  tumor 
in  the  apparently  unaffected  ovary,  it  should  be  also  removed— otherwise 
a  subsequent  operation  will  be  demanded  and,  in  the  case  of  malignancy, 
the  second  operation  may  come  too  late  to  save  the  patient. 

There  is  a  point  in  the  technic  of  the  removal  of  ovarian  tumors  which 
experience  has  taught  me  never  to  neglect.    The  uterus  should  always  be 


170  ATLAS  OF  OPERATIVE  GYNECOLOGY 

suspended  by  a  single  strand  of  number  3  catgut ;  otherwise  the  weight  of  the 
ovarian  stump  on  the  posterior  surface  of  the  broad  Hgament  is  apt  to  pull 
the  uterus  over  backward  and  to  result  in  an  adherent  retroversion.  Until 
I  learned  this  lesson,  I  found  it  necessary  to  reopen  the  abdomeii  in  quite 
a  number  of  cases  to  correct  the  adhesion  of  the  ovarian  stump  to  the 
tissues  on  the  posterior  wall  of  the  pelvic  cavity. 

In  i)artial  ocipliorectomy  the  cyst  or  diseased  area  of  the  ovary  should 
be  c()m])letely  dissected  out.  This  is  particularly  important  in  the  former 
case  in  order  that  all  the  secreting  surface  of  the  cystic  tumor  shall  be 
removed,  otherwise  there  will  be  a  reformation  of  tlic  cyst. 

The  wound  loft  in  the  o\ary  l)y  this  operation  should  })e  united  by  inter- 
rupted plain  number  1  catgut  sutures.  The  two  corners  of  the  wound  are 
first  sutured  and  the  ends  of  the  sutures  are  left  long.  As  an  assistant  hokls 
these  up  and  apart,  the  rest  of  the  ovarian  wound  is  easily  and  conveniently 
united.  The  interrupted  stitch  will  be  found  to  give  much  the  best  approxi- 
mation; the  running  stitch  rarely  unites  the  o^'arian  wound  satisfactorily. 

In  removing  intraligamentary  cysts  without  a  pedicle,  a  transverse 
incision  is  made  in  the  anterior  face  of  the  broad  ligament,  avoiding  import- 
ant blood  vessels ;  then  with  the  fingers,  or  a  blunt  dissection  by  closed  blunt 
pointed  scissors,  the  tumor  is  shelled  out  of  its  bed.  Sometimes  a  more 
convenient  place  to  make  the  first  incision  in  the  broad  ligament  is  in  its 
free  lateral  border;  occasionally  it  may  be  found  more  convenient  to  make 
the  incision  ])()steriorly.  This  can  be  judged  by  an  inspection  of  the  tumor 
after  it  is  exposed  to  touch  and  sight.  After  the  enucleation  of  the  tumor, 
a  deep  raw  bed  may  be  left.  As  far  as  })ossible,  the  upper  walls  of  this 
bed  are  cut  away.  It  may  then  be  possible  to  close  the  sack  by  sutures, 
obliterating  the  dead  spaces  within  it ;  but  in  doing  so  it  must  be  remembered 
that  the  ureter  runs  along  the  base  of  the  sack,  so  that  deep  suturing  in 
this  region  must  be  avoided  unless  the  ureter  is  dissected  out  and  exposed 
to  ^■iew,  as  in  the  Wertheim  operation. 

If  it  is  impossible  successfully  to  dispose  of  the  bed  of  an  intraliga- 
mentary cyst  otherwise,  it  may  be  marsupialized  and  fastened  to  the  abdom- 
inal wall,  through  which  it  is  tlrained  by  a  strip  of  gauze,  a  cigarette  drain, 
or  a  rul)ber  tube  until  its  cavitv  is  obliterated. 


PLATE  CIX. 


Pedicle  clamped  f<.>r  lh  'plitjiLctLin} . 


12 


PLATE  ex. 


Interlacing  ligatures  of  stump  after  oophorectomy. 


MYOMECTOMY  173 

MYOMECTOMY 

Abdominal. — In  the  surgical  treatment  of  fibroid  tumors  one  of  the 
most  difficult  questions  to  decide  is  whether  to  remove  the  tumor  alone  or 
to  do  a  hysterectomy.  It  is  usually  impossible  to  decide  this  question  until 
the  tumor  is  exposed  to  sight  and  touch,  and  an  operation  for  a  fibroid 
tumor  should  only  be  undertaken  with  the  understanding  that  the  surgeon 
should  exercise  his  judgment  as  to  the  proper  operation  after  he  has  exposed 
the  tumor.  Patients  are  sometimes  disposed  to  exact  promises  that  they 
shall  not  be  mutilated,  and  require  an  assurance  that  the  tumor  alone  will 
be  removed.  It  is  perfectly  proper  for  the  patient  to  express  a  wish  of  this 
kind;  but  it  must  be  understood  that  the  surgeon,  while  bearing  in  mind 
the  patient's  desire,  is  free  to  exercise  his  best  judgment  during  the  operation. 

A  number  of  considerations  must  be  taken  into  account  in  coming  to  a 
correct  decision.  In  the  first  place,  generally  speaking,  myomectomy  is 
more  dangerous  than  hysterectomy,  except  in  subperitoneal  tumors  with 
a  small  pedicle.  There  is  no  special  reason  for  myomectomy  in  a  woman 
approaching  the  menopause  who  has  no  hope  for  child-bearing  and  in  whom 
the  menstrual  function  will  soon  cease.  If  the  tubes  are  so  diseased  that 
they  must  be  removed,  there  is  no  good  reason  for  myomectomy  in  prefer- 
ence to  hysterectomy.  If  the  patient  is  indifferent  in  regard  to  conception, 
a  hysterectomy  is  usually  preferable.  If  there  is  the  sUghtest  suspicion  as 
to  the  character  of  the  tumor,  as  to  a  possibility  of  sarcomatous  degeneration, 
myomectomy  is  ob\-iously  improper.  If  the  patient's  physical  condition 
is  poor,  if  her  haemoglobin  percentage  is  low,  hysterectomy  is  preferable. 
If  the  tumor  is  situated  in  the  broad  ligament  it  must  be  remembered  that 
the  closure  of  the  tumor  bed  is  much  more  diflncult  than  if  it  were  situated 
in  the  uterine  wall,  and  there  is  much  greater  danger  of  hjematoma  and 
infection  of  the  tumor  bed  subsequent  to  the  operation;  if  the  tumor  is 
submucous,  either  a  vaginal  myomectomy  or  an  abdominal  hysterectomy 
is  preferable  to  an  abdominal  mj-omectomy;  for  it  is  undesirable  to  open  the 
uterine  cavity  during  the  operation,  on  account  of  a  possible  infection  of 
uterine  wound  extending  to  the  perimetrium  and  thus  causing  fatal  perito- 
nitis. If  the  tumor  is  multiple  and  a  number  of  incisions  in  the  uterine 
wall  are  necessary,  a  hysterectomy  is  usually-  preferred. 

I  have,  however,  removed  five  myomata  through  as  many  incisions 
in  a  woman  sterile  for  thirteen  years  after  marriage,  who  conceived  three 
months  after  the  operation. 

As  arguments  on  the  other  side  of  the  question,  the  following  facts 
must  be  considered : 

If  the  operation  is  performed  on  a  comparatively  young  married  woman 
desirous  of  maternity,  the  hkelihood  of  conception  after  a  myomectomy 
must  be  taken  into  account.     Winter's  statistics  show  18-20  per  cent,  of 


174  ATLAS  OF  OPERATIVE  GYN.I^COLOGY 

conceptions  after  myoinectoni}-  in  women  under  fort}-  years  of  age.  If  the 
tumor  is  subperitoneal  or  interstitial,  single,  and  moderate  in  size;  if  the 
patient's  physical  condition  is  good  and  her  haemoglobin  percentage  is 
fairly  high;  if  there  is  no  suggestion  of  malignant  change  in  the  tumor — 
mj'omectomy  may  be  the  preferable  operation.  If  the  tumor  is  subperito- 
neal, with  a  small  pedicle,  there  is  no  question  about  the  advisability  of 
mjomectomy. 

These  questions  must  be  considered  and  a  rapid  decision  made  after 
careful  inspection  and  palpation  of  the  tumor,  taking  into  accoinit  the 
patient's  contlition  and  history.  Technically,  the  operation  of  myomectomy 
is  comparatively  easy  if  the  tumor  is  situated  in  the  uterine  wall  well  above 
the  level  of  the  internal  os.  A  lower  situation  makes  the  operation  techni- 
cally difficult  and  usually  undesirable. 

An  incision  is  made  directly  over  the  tiunor  long  enough  to  extract  it 
without  tearing  the  uterine  wall.  When  the  tumor  surface  is  reached,  the 
uterine  wall  is  stripped  back  sufficientlj'  far  to  enable  a  firm  grasp  to  be 
taken  of  the  tumor  by  a  volsellum  forceps;  then,  with  the  finger  or  knife- 
handle  or  a  dissector,  the  tumor  is  easily  enucleated  from  its  bed.  The 
most  imjiortant  featiuT  of  the  operation  is  an  accurate  closure  of  the  tumor 
bed.  I  have  found  it  easier  to  accomplish  this  by  successive  rows  of  inter- 
rupted sutures  of  a  number  3  catgut  on  a  cur\ed,  round-pointed  needle. 
After  the  bed  of  the  tumor  is  comjiletely  closed  by  the  successive  layers  of 
sutures,  the  peritoneal  investiture  of  the  uterus  is  securely  closed  by  a  run- 
ning suture  up  and  down  the  wound,  which,  when  completed,  makes  the 
laced  suture  look  like  a  shoelace  and  secures  a  more  accurate  closure  of 
the  perim(>trium  than  any  kind  of  stitch. 

Even  with  the  most  accurate  closure,  however,  of  the  external  uterine 
wound,  there  is  pro\'ocation  to  extensive  adhesions  afterward  between  the 
uterus  and  neighboring  structures.  It  is  often  necessary,  therefore,  to  con- 
sider the  susjiension  of  the  uterus  diu'ing  the  time  required  for  healing  of 
the  woimd;  this  I  ha\'e  always  accomjjlished  by  a  single  strand  of  number  3 
gut  fastening  the  uterine  fundus  to  the  abdominal  peritoneum,  which  secures 
a  temporary  suspension  and  does  much  to  prevent  undesirable  adhesions 
to  the  uterus  during  the  period  of  surgical  convalescence. 

The  existence  of  pregnancy  sometimes  makes  the  decision  between 
myomectomy  and  hysterectomy  unusually  difficult;  but  it  must  be  remem- 
bered that  myomectomy  is  quite  jiossible  during  pregnancy  without  inter- 
rupting the  woman's  condition.  In  common  with  all  operators  of  experience, 
I  have  removed  fibroid  tumors  by  myomectomy  both  from  the  uterine  wall 
and  from  the  broad  ligament  without  interrupting  gestation ;  but  the  oper- 
ation is  more  difficult  in  this  condition  than  otherwise,  on  account  of  the 
vascularity  of  the  tumor  bed. 


IVIYOMECTOMY  175 

As  a  rule,  an  operation  for  a  fibroid  tumor  during  pregnancy  should  be  a 
hysterectomy  and  not  a  myomectomy,  and  if  possible  the  operation  should 
be  postponed  until  a  date  in  pregnancy  when  a  coincident  csesarean  section 
and  hysterectomy  will  secure  at  the  same  time  the  removal  of  the  tuiiKjr 
and  the  birth  of  a  \'iable  infant. 

Vaginal  Myomectomy. — This  operation  is  most  suitable  for  cervical 
myomata  and  for  submucous  fibroids;  the  latter  are  usually  best  dealt  with 
by  a  preparatory  anterior  vaginal  hysterotomy.  By  this  means  the  surface 
of  the  tumor  is  exposed,  and  e\en  alt  hough  only  a  small  area  is  made  accessible 
it  is  sufficient  to  grasp  the  tumor  with  a  volsellum  forceps  and  to  begin  its 
removal  by  morcellation.  It  is  surprising  how  large  a  tumor  may  be  removed 
in  this  manner;  a  tumor  quite  as  large  as  a  fetal  head  can  be  dealt  with 
successfully  by  patience  and  persistence.  A  small  submucous  growth  can 
readily  be  enucleated  from  under  the  mucous  membrane,  which  is  first 
incised  until  the  tumor  itself  ajipears  in  view,  and  then,  as  in  the  case  of 
abdominal  myomectomy,  the  tumor  is  enucleated  by  the  finger,  a  knife 
handle,  or  blunt  pointed  closed  scissors.  In  rare  instances  the  removal  of 
submucous  fibroids  is  made  particularly  easy  by  an  inversion  of  the  uterus, 
which  has  been  caused  by  a  fibroid  dependent  from  the  fundus.  In  such  a 
case,  enucleation  must  be  followed  by  Spinelli's  operation  for  inversion  of 
the  womb  if  it  cannot  be  reduced  by  taxis. 

In  a  cervical  myoma,  vaginal  enucleation  is  almost  alwaj's  to  be  pre- 
ferred. The  operation  is  easy  if  the  tumor  is  small;  but  is  practicable  even 
in  tumors  of  large  size,  in  which  the  uterus  proper  sits  upon  the  top  of  a 
growth  larger  than  the  fetal  head.  An  incision  is  made  directly  o\-er  the 
most  prominent  portion  of  the  tumor,  the  incision  usually  being  made 
upon  the  vaginal  portion  of  the  cervix  or  through  the  mucous  membrane  of 
a  vaginal  vault.  As  soon  as  the  tumor  wall  proper  is  exposed  it  is  seized 
with  a  \-olsellum  forceps  and  then  enucleated  if  its  size  is  small,  or  morcel- 
lated  by  the  excision  of  piece  after  piece  until  finally  the  remaining  small 
part  of  the  growth  can  be  extracted  after  enucleation  (Plates  CXI-C'XVII). 

A  large  cavity  is  left  behind,  which  is  packed  with  gauze;  in  vaginal 
myomectomy  a  closure  of  the  tumor  cavity  by  suture  is  usually 
impracticable. 

The  packing  is  left  in  place  fortj^-eight  hours.  If  there  is  much  oozing 
on  its  removal,  it  may  be  necessary  to  irrigate  the  tumor  cavity  and  to  repack; 
but  it  is  surprising  to  see  how  cjuickly  large  tumor  cavities  are  reduced  in 
size  until  they  are  obliterated.  It  is  also  surprising  to  observe  how  little 
hemorrhage  there  is  from  these  large  tumor  ca\uties  after  \-aginal  myomec- 
tomy. In  exceptional  cases,  in  which  hemorrhage  maj'  be  troublesome,  it 
can  be  controlled  by  a  sufficiently  firm  pack. 

In  undertaking  the  removal  of  a  fibroid  tmuor   by  the  vagina,  the 


176  ATLAS  OF  OPERATIVE  GYNECOLOGY 

operator  must  be  preiiared  for  unexpected  difficulties  and  may  have  to 
resort  to  an  abdominal  section  to  finish  the  operation. 

It  may  be  necessary  to  remove  infected  and  sloughing  myomata  from 
the  uterine  cavity,  especially  after  childbirth,  as  they  are  particularly  prone 
to  degeneration  and  infection  after  that  process.  In  such  cases  naturally 
the  vaginal  operation  is  to  be  preferred.  But  I  have  been  obliged  to  resort 
to  abdominal  hysterectomy  in  a  large  submucous  fibroid  tumor  with  strep- 
tococcic infection  and  the  patient  in  a  truly  desperate  condition;  but  fortu- 
nately the  operation  resulted  in  her  recovery.  As  a  rule  it  is  unwise  to  open 
the  uterine  cavity  through  an  abdominal  incision  in  order  to  get  at  the  tumor; 
so  that,  if  the  vaginal  operation  is  impracticable,  the  abdominal  operation 
should  be  a  hysterectomy,  although  the  tumor  would  ordinarily  be  a  suitable 
one  for  myomectomy. 

In  some  of  these  cases  the  patient's  local  and  general  condition  is  so 
bad  that  the  surgeon  is  loath  to  undertake  any  operative  interference. 
In  one  such  case  of  necrotic  infected  submucous  myoma  following  childbirth, 
I  secured  recovery  by  spraying  the  uterine  ca\ity  with  dichloramin-T until 
the  whole  tumor  gradually  sloughed  away  and  the  patient  eventually  made  a 
perfect  recovery. 


PLATE  CXI. 


Incision  of  uterine  wall  inr  niyonn.'<.'toniy. 


PI>ATE  CXII. 


Enucleation  of  tunicjr. 


PLATE  CXIII. 


"X 


N. 


X 


\ 


\ 


Closure  of  tumor  bed. 


PLATE  CXIV. 


Closure  of  tumor  bed  by  second  row  of  interrupted  sutures. 


PLATE  CXV. 


Closure  of  uterine  wall. 


PLATE  CXVI. 


Enucleation  of  fibroid  tumor  of  moderate  size  by  vaginal  route. 


PLATE  CXVII. 


-M 


Enucleation  of  fibroid  tumor  of  moderate  size  by  vaginal  route. 


184  ATLAS  OF  OPERATIVE  (.YN.^XOLOGY 

HYSTERECTOMY 

Of  all  the  operations  performed  upon  women,  hysterectomy  has  perhaps 
the  f);reatest  variety  of  indications  and  of  technic. 

There  is  the  supravaginal  amputation  of  the  womb  by  the  abdominal 
route;  panhysterectomy  by  abdominal  section;  panhysterectomy  with 
exsection  of  the  parametrium  (Wertheim's  extended  operation) ;  partial  or 
cuneiform  hysterectomy  involving  the  fundus  or  one  wall;  cuneiform 
hysterectomy  involving  posterior  and  anterior  walls  with  exsection  of  the 
endometrium;  supravaginal  extraperitoneal  hysterectomy  by  the  vaginal 
route,  and  vaginal  hysterectomy. 

Supravaginal  Amputation  of  the  Uterus  by  Abdominal  Section. — 
This  is  the  kind  of  hysterectomy  more  frequently  performed  than  all  the 
rest  put  together.  It  is  the  usual  method  of  treating  a  fibroid  tumor.  It  is 
often  employed  when  the  appendages  are  removed  for  inflammatory  con- 
ditions. It  may  be  demanded  bj'  an  infection  of  the  uterus,  by  suppurative 
metritis,  and  by  streptococcic  necrosis.  It  is  also  one  of  the  methods  of 
performing  csesarean  section.  Associated  with  this  form  of  hysterectomy 
is  usually  the  removal  of  a  part  or  all  of  the  appendages. 

The  common  practice  is  to  leave  one  ovary  in  the  abdominal  cavity, 
when  the  body  of  the  uterus  is  removed,  with  the  idea  of  saving  the  woman 
the  disagreeable  symptoms  of  the  precipitate  menopause;  but  the  result  of 
this  practice  has  not  been  altogether  satisfactory.  It  has  been  too  frequently 
found  that  the  ovary  later  undergoes  cystic  or  other  degeneration  and  gives 
rise  to  such  troublesome  symptoms  that  the  abdomen  must  again  be  opened 
for  its  removal.  This  has  been  my  experience  so  often  that  I  confess  to  a 
prejudice  against  leaving  one  ovary  behind  in  performing  a  supravaginal 
hysterectomy.  Possibly  this  difficulty  will  be  obviated  in  the  future  by 
leaving  the  tube  and  broad  ligament  with  the  ovary  in  order  to  preserve  its 
normal  circulation. 

The  observations  of  Polak,  in  the  Long  Island  College  Hospital  in 
Brooklyn,  would  appear  to  confirm  this  view ;  and  I  shall,  in  the  future,  adopt 
this  procedure  in  women  who  are  still  comparatively  young.  If  they  are 
near  the  menopause  there  is  no  sufficient  reason  for  leaving  an  ovary  behind, 
and  in  such  women  it  has  been  my  uniform  practice  to  remove  all  the  append- 
ages with  the  body  of  the  uterus.  The  transplantation  of  one  ovary  in  the 
abdominal  wall  has  had  a  vogue  in  these  cases;  but  I  agree  with  Graves  that 
the  only  purpose  of  this  procedure  is  to  comfort  the  patient's  mind  with  the 
illusion  that  she  still  possessed  a  sexual  gland.  Nothing  else  can  be  accom- 
plished by  it,  as  the  ovary  rapidly  degenerates,  ceases  to  ovulate  and  cannot 
possibly  influence  the  rest  of  the  body  by  its  internal  secretions. 

The  technic  of  supravaginal  hysterectomy  varies  as  one  determines  to 
leave  an  ovary,  or  an  ovary  and  a  tube,  or  decides  upon  the  removal  of  all 


HYSTERECTOMY  185 

of  the  appendages.  The  patient  is  raised  in  a  moderate  Trendelenburg  posi- 
tion; the  tumor  is  deUvered.  The  intestines  are  packed  off  with  a  large 
soft  gauze  pad.  A  self-retaining  abdominal  retractor  distends  the  abdominal 
wound.  The  series  of  illustrations  ( Plates  C'XVIII-CXX)  show  an  operation 
in  which  all  of  the  appendages  are  removed;  but  it  is  easy  to  vary  this 
technic  by  placing  forceps  to  control  hemorrhage  above  the  ovary  and  below 
the  tube — in  case  the  former  alone  is  preserved;  or  by  placing  the  forceps 
along  the  broad  ligament  embracing  its  entire  depth,  one  being  placed  next 
the  uterus  and  the  other  just  beyond  it  laterally  (Plate  CXXI). 

The  round  ligament  is  clamped  separately  (Plate  C'XXIII)  if  a  forceps 
is  put  on  the  free  edge  of  the  broad  ligament.  In  order  to  prevent  reflux 
bleeding  a  clamp  is  placed  along  the  side  of  the  uterus  embracing  the  tube 
and  the  upper  portion  of  the  broad  ligament  to  catch  the  anastomosis  of  the 
ovarian  and  uterine  arteries.  These  clamps  being  fastened,  the  broad  liga- 
ment is  cut  toward  the  uterus  in  a  direction  diagonally  inward  and  down- 
ward until  the  lateral  wall  of  the  cervix  is  reached  and  the  uterine  artery  is 
exposed.    This  is  clamped  (Plate  CXXIV)  and  cut. 

After  the  three  arteries  on  each  side  are  severed  and  the  whole  broad 
ligament  is  cut  across,  the  cervix  is  encircled  by  an  incision  high  enough  to 
leave  a  flap  of  peritoneum  anteriorly  and  posteriorly ;  in  the  former  situation 
the  bladder  is  at  the  same  time  separated  from  its  attachment  to  the  cervix. 
The  cervix  is  then  cut  across  in  such  a  manner  as  to  leave  an  inverted  wedge. 
As  soon  as  the  uterus  is  amputated  and  removed,  the  cervical  canal  is  burned 
out  with  a  cautery  knife,  as  it  is  possible  the  canal  may  be  infected.  Ordi- 
narily it  is  sterile,  but  not  invariably  so ;  therefore  the  precaution  of  cauter- 
izing the  canal  is  a  safe  one.  As  soon  as  this  is  accomplished,  interrupted 
sutures  are  passed  through  the  myometrium  of  the  cervix  from  before  back- 
ward on  either  side  of  the  canal  and  one  in  the  middle  closing  the  cervical 
tissues  over  the  canal  ( Plate  CXXV) .  These  ligatures  should  be  of  number  3 
plain  gut.  The  next  step  in  the  operation  is  the  peritonealization  of  the 
stump  (Plate  CXXVI)  and  the  attachment  of  the  infundibulopelvic  and 
round  ligaments  to  the  parametrium  or  to  the  cervix  itself.  This  can  be 
done  by  the  stitch  illustrated  in  the  drawing  (Plate  CXXM),  or  this  stitch 
can  be  modified  by  putting  a  single  interrupted  suture  on  each  side  of  the 
cervix,  catching  in  succession  the  anterior  flap  of  the  broad  Ugament,  the 
parametrium,  the  end  of  the  round  ligament,  the  stump  of  the  ovarian 
artery,  the  parametrium  again,  and  the  posterior  flap  of  the  broad  ligan:ent. 
^^^len  this  single  stitch  is  tied,  as  may  be  seen,  the  two  Hgaments  are  brought 
into  close  contact  with  the  cervix  and  the  upper  edge  of  the  broad  ligament 
wound  on  each  side  of  the  cervix  is  peritoneahzed  (Plate  C'XXVH).  The 
peritoneum  is  then  stitched  over  the  cervical  stump  and  the  operation  is 
concluded  (Plate  CXXVIII). 


PLATE  CXVIII. 


Supravaginal   hysterectomy   for   fibromyoma    uteri.      Uvaiian   artery   and   artery   of    round   ligament   clamped. 
Both  broad  ligaments  clamped  to  control  reflux  bleeding. 


PLATE  CXIX. 


13 


Broad  ligament  cut  and  uterine  artery  on  right  side  clamped  "and  cut. 


PLATE  CXX. 


All  six  Hrteries  clamped  eeparately.     Uterus  cut  away  from  cervix. 


PLATE  CXXI. 


Supravaginal  hysterectomy  leaving  both  tubes,  broad  ligaments,  and  ovaries;  the  edges  of  the  broad  ligaments  can 
be  sewed  together  in  the  middle  line  or  the  raw  edges  can  be  whipped  together  from  side  to  side. 


PLATE  CXXII. 


Supravaginal  hysterectomy.     The  three  arteries  on  each  side  clamped  and  the  right  ovarian  artery  being  ligated. 


PLATE  CXXIII 


Ligation  of  artery  of  round  ligament  by  a  lit;:tiuM  \\  Imh  i'  i  -  u  t  transfix  the  tissues. 


PLATE  CXXIV. 


The  uterine  artery  ligated  by  a  ligature  passed  to  its  inner  side  and  tied  both  un  the  inner  and  the  outer  side 

of  the  clamp. 


PLATE  CXXV. 


Cervical  stump  closed  after  cauterization  of  carml. 


IM.ATK  CXXVI. 


.Suture  of  peritoiieuru  <tvei  stutup  in  sutli  iimnner  as  to  invert  stumps  of  arteries  and  attached  ligaments  to  cervical  stump 

and  to  completely  peritonealize  the  stump. 


PLATE  CXXVII. 


Conclusion  uf  operation  by  peritonealization  of  cervix. 


PLATE  CXXVII 


Operation  concluded. 


HYSTERECTOMY  197 

Panhysterectomy. — This  form  of  hysterectomy  is  required  for  the 
removal  of  all  malignant  growths;  but  it  is  also  preferred  by  some  operators, 
instead  of  the  supravaginal  amputation — as,  for  instance,  in  the  removal 
of  fibroid  tumors  and  of  the  uterus  along  with  inflamed  appendages. 
Personally,  I  prefer  to  leave  the  cervix  whenever  possible,  as  the  total 
removal  of  the  uterus  makes  the  vagina  shallow  and  deprives  the  tissues  of 
the  jielvic  cavity  of  support  which  is  desirable  for  the  future  comfort  of  the 
patient.  Future  marital  relations  must  also  be  considered.  If  a  pan- 
hysterectomy is  performed,  not  for  malignancy  but  because  the  operator 
prefers  this  operation,  the  technic  is  as  follows: 

The  broad  ligaments  are  secured  as  in  the  supravaginal  amputation; 
the  round  ligaments  are  clamped  in  the  same  way.  Reflux  bleeding  is  pre- 
vented in  the  same  manner;  the  bladder  is  separated  from  the  cervix;  and, 
by  a  blunt  dissection,  the  uterovesical  pouch  is  deepened  until  a  point  on 
the  vaginal  wall  is  reached  below  the  level  of  the  external  os.  The  utero- 
sacral  ligaments  are  severed  and  a  blunt  dissection  frees  the  posterior  vaginal 
wall  downward,  until  the  operator  feels  between  his  fingers  the  tip  of  the 
cervix  well  above  the  deepest  ]>ortion  of  his  blunt  dissection.  The  uterine 
arteries  are  then  caught  as  low  as  possible  before  they  turn  upward  along 
the  uterine  wall.  These  arteries  are  severed,  and  a  blunt  dissection  is  made 
of  the  tissues  lateral  to  the  cervix  until  the  depth  of  the  dissection  equals 
that  anteriorly  and  i)osteriorly.  The  vaginal  wall  is  then  clamped  on  each 
side  by  a  Wertheim  forceps  and  the  vagina  is  cut  across,  leaving  a  consider- 
able cuff  of  it  attached  to  the  cervix. 

Before  undertaking  this  operation,  it  is  naturally  essential  to  disinfect 
the  \'agina  thoroughly  and  to  pack  it  with  sterile  gauze.  If  there  is  anj' 
doul)t  as  to  the  freedom  from  bacteria  of  the  cervical  canal  and  uterine 
cavity,  the  uterus  is  injected  with  pure  formalin;  and  the  cervix  is  closed  by 
a  running  stitch,  after  the  formalin  has  been  allowed  amjile  time  to  escape. 
In  addition,  the  Sigwart  clamp  may  be  used  to  close  the  vaginal  cuff  above 
the  site  of  the  transverse  incision  which  separates  it  and  frees  the  uterus. 
The  peritonealization  of  the  wound  is  conducted  in  the  same  manner  as  in 
a  supravaginal  hysterectomy,  except  that  the  round  ligament  and  the 
infiuulil)uloi)elvic  ligaments  are  fastened  to  the  lateral  edges  of  tlie  incision 
across  the  vaginal  walls,  in  order  to  prevent  a  prolapse  of  the  vagina. 

Extended  Panhysterectomy  for  Carcinoma  of  the  Uterus. — 
Panhysterectomy  has  been  gradually  develoiJed,  since  Freund's  original 
operation,  by  a  number  of  surgeons,  including  Clark  of  this  country  and  most 
particularly  Wertheim  of  Vienna — whose  large  experience  has  enabled  him 
to  standardize  the  ojieration  and  to  introduce  it  to  the  profession  in  general, 
with  greater  authority  than  any  other  single  operator  in  the  world.  (Plates 
(CXXIX-CXXXIII.)     Whether  this  extended  operation  for  carcinoma  is 


198  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

worth  the  high  primary  inortaUty  is  still  questioned  by  some  gynaecologists; 
but  the  majority  of  cxjiorionccd  operators  will,  I  think,  agree  with  Peterson, 
of  Ann  Arbor,  who  finds  the  ultimate  result  after  five  years  sufficiently 
satisfactory  to  justify  a  cf)ntinuance  of  the  operation.  Wertheim's  large 
experience  also  confirms  this  view. 

Although  many  were  originally  prejudiced  against  the  operation  on 
account  of  its  technical  difficulty  and  high  primary  mortality,  the  large 
majority  of  experienced  operators  are  now  completely  convinced  that  it  is 
the  duty  of  the  surgeon  to  gi\-e  his  patient  the  chance  afforded  by  this  opera- 
tion for  permanent  cure  if  there  is  any  possibility  of  carrying  it  out  with 
a  fair  chance  of  immediate  recovery. 

In  the  last  five  years  my  statistics  have  been  so  satisfactory  in  regard 
to  primary  mortality  that  the  prejudice  I  originally  entertained  against  the 
operation  has  completely  disappeared. 

In  this  time  mentioned  (five  years)  I  have  done  forty  of  these  extended 
operations  with  only  three  deaths — a  mortality  of  seven  and  one-half 
per  cent.  The  number  of  operations  quoted,  it  must  be  confessed,  is  too 
small  to  base  an  opinion  on,  but  if  it  is  possible  to  carry  out  this  operation 
with  not  much  more  primary  mortality  than  this,  the  ultimate  result  gen- 
erally justifies  the  procedure. 

Unfortunately,  in  the  large  American  cities,  it  is  impossible  to  follow 
up  end  results  after  so  long  a  period  as  five  years.  But  I  think  that  most  of 
us  can  count  upon  the  end  results  recorded  by  Dr.  Peterson — namely, 
sixty-two  to  sixty-nine  per  cent,  of  permanent  cures  in  those  who  survived 
the  operation;  the  highest  percentage  of  permanent  cures  naturally  being 
obtained  in  cancers  of  the  fundus,  while  the  worst  results  are  shown  by 
cancers  of  the  cervix. 

As  cancers  of  the  fundus  have  always  given  a  better  primary  and  ulti- 
mate mortality  than  cancers  of  the  cervix,  the  question  naturally  arises 
as  to  whether  the  extended  operation  should  be  done  in  cancers  of  the 
fundus;  or  whether,  on  account  of  its  high  mortality,  one  should  content 
himself  with  the  ordinary  panhysterectomy  without  the  wide  dissection  of 
the  broad  ligaments  or  the  removal  of  a  largo  ]>ortion  of  the  parametrium. 

Personally,  I  belie\'e  in  the  extended  operation  even  for  cancers  of  the 
fundus;  it  is  an  easier  operation  than  that  for  cancer  of  the  cervix,  and  it 
would  appear  from  the  study  of  American  and  European  statistics  that  the 
chance  of  permanent  recovery  in  this  form  of  cancer  is  distinctly  increased 
by  the  extended  operation  as  compared  with  the  ordinary  panhysterectomy. 

After  witnessing  a  performance  of  this  operation  by  Wertheim  in  his 
own  clinic  and  by  Sigwart  in  Bumm's  clinic  in  Berlin,  my  choice  has  been 
for  a  combination  of  the  technic  of  the  two  medical  centres  as  follows: 
A  long  median  incision  reaching  to  the  symphysis  opens  the  abdomen. 


HYSTERECTOMY  199 

A  permanent  retractor  is  adjusted;  the  patient  is  raised  in  the  Trendelen- 
burg position;  the  intestines  are  well  packed  off  with  gauze  pads  and  the 
operation  proper  is  begun  by  a  ligation  of  the  ovarian  arteries.  The  catgut 
ligature  used  for  this  purpose  is  left  long  and  fastened  to  the  sheet  covering 
the  woman's  abdomen  toward  her  head.  Next  the  round  ligaments  are 
ligated;  the  ligature  again  is  left  long,  and  fastened  to  the  sheet  toward  the 
woman's  knees.  An  incision  is  then  made  severing  the  outer  lateral  edge 
of  the  broad  ligament,  and  with  it  the  ovarian  artery.  The  incision  is  then 
carried  upward  on  the  free  edge  of  the  broad  ligament  toward  the  mesentery 
of  the  large  intestine.  The  incision  is  then  extended  downward  and  inward, 
severing  the  anterior  face  of  the  broad  ligament  and  separating  the  blailder 
from  the  cervix.  The  base  of  the  broad  ligament  is  then  exposed  by  blunt 
dissection,  and  1  find  the  Goffe  dissector  a  useful  instrument  for  this  purpose. 
The  dissection  is  continued  until  the  ureter  is  well  exposed  and  the  uterine 
artery  is  seen;  the  latter  is  then  seized  by  a  hsmostat  forceps  and  elevated, 
while  the  forefinger  of  the  operator  is  passed  under  it  and  over  the  ureter. 
The  artery  is  then  severed  to  the  outer  side  of  the  ureter,  the  whole  extent 
of  which  is  then  visible  running  across  the  base  of  the  broad  ligament  and 
entering  the  bladder. 

The  posterior  face  of  the  broad  ligament  is  then  slit  from  above  down- 
ward and  the  uterosacral  ligaments  are  se^■ered.  An  incision  through  the 
peritoneum  of  Douglas's  pouch  connects  the  incision  severing  the  ligaments, 
and  is  extended  outward  to  meet  the  incision  running  downward  through  the 
posterior  face  of  the  broad  ligament.  The  connective  tissue  of  the  pelvis 
and  the  parametrium  is  then  completely  exposed.  Infected  glands  are 
carefully  felt  and  looked  for.    If  found,  they  are  naturally  renio\ed. 

The  Wertheim  clamps  are  then  adjusted  so  that  a  considerable  portion 
of  the  parametrium  will  be  removed  with  the  uterus  and  a  cuff  of  the  \-agina. 
The  Sigwart  clamp  is  then  adjusted  aliove  the  Wertheim  clamp  anil  the 
vagina  is  severed  between  the  two.  The  walls  of  the  latter  are  innr.ediately 
seized  and  closed  with  interrupted  sutures  of  catgut.  Then  with  a  curved 
needle,  threaded  with  number  3  catgut,  the  lateral  fornices  of  the  vagina 
are  transfixed  to  the  inner  side  of  the  point  of  the  Wertheim  clamps.  The 
ligature  is  then  tied  outward,  and  in  this  way  the  uterovaginal  plexuses 
of  veins  are  secured  and  a  bleeding,  which  was  extremely  troublesome  before 
the  use  of  the  Wertheim  clamp  became  general,  is  satisfactorily  a^■oided. 
The  peritoneum  is  now  united  in  such  a  manner  that  the  dead  space  between 
the  peritoneal  fold  and  the  \'aginal  wall  is  obliterated  by  taking  in  the  upper- 
most portion  of  the  latter  with  the  needle  that  sutures  the  peritoneum. 
The  infundibulopelvic  ligament  and  the  round  liganient  are  fastened  to  the 
outer  edges  of  the  vagina  by  the  kind  of  stitch  shown  in  the  Plate  CXXVI. 
It  not  only  fastens  the  ends  of  these  ligaments  to  the  vaginal  wall  in  order 


200  ATLAS  OF  OPERATIVE  GYNECOLOGY 

to  support  them,  but  when  the  ligature  is  tied  the  stumps  of  these  Ugaments 
are  turned  in  between  the  layers  of  the  peritoneum  constituting  the  anterior 
and  posterior  layers  of  the  l)road  ligament.  The  sterilization  of  the  vagina, 
cervix,  and  uterine  cavity,  before  liegiiming  the  operation,  is  of  the  greatest 
importance.  The  vagina  is  washed  out  with  lysol,  one  ])er  cent.;  then  with 
alcohol ;  and  then  painted  with  iodine.  If  there  is  a  sloughing  cervical  cancer 
it  is  cauterized,  and  in  any  event  the  interior  of  the  uterus  is  sterilized  by 
the  injection  of  pure  formalin  with  a  Braun  intrauterine  syringe.  If  the 
patient  escapes  the  immediate  danger  of  the  operation,  the  recovery  is 
remarkably  smooth  and  uneventful  as  a  rule.  The  complete  peritonealiza- 
tion  of  the  i)elvic  wound  and  the  cleanly  nature  of  the  operation  (done 
with  proper  asepsis  and  antiseptic  precautions)  necessarily  contrilnite  to  an 
uncomplicated  convalescence;  but  unfortunately  tlie  operation  is  a  tedious 
one,  and  the  strain  on  the  patient's  heart  and  ner\()us  system  is  severe.  It 
will  be  an  interesting  observation  in  the  future  to  note  a  possible  improve- 
ment in  mortality  by  the  utilization  of  gas  and  oxygen  ansesthesia  with  a 
limitation  of  the  time  the  patient  is  held  in  the  Trendelenburg  position. 
I  feel  confident  that  a  good  many  of  the  tleaths  from  the  Wertheim  opera- 
tion are  due  to  long-continued  use  of  ether  or  chloroform  and  to  a  prolonged 
elevation  of  the  hii)s;  and  I  believe  that  the  future  will  show  a  gratifying 
reduction  in  primary'  mortality,  if  gas  and  oxygen  ana-sthesia  are  substituted 
for  the  anaesthetics  formerly  in  more  general  use,  and  if  the  table  is  lowered 
as  soon  as  the  deeper  work  in  the  pelvis  is  comjileted. 

The  after-treatment  is  by  the  Murphy  drip  of  a  ([uart  of  water  contain- 
ing an  oimce  of  bicarbonate  of  soda  and  an  ounce  of  glucose.  The  use  of 
cartliac  and  general  stimulants  is  more  important  after  this  abdominal 
section  than  possibly  any  other.  Here  again,  by  a  careful  attention  to  the 
after-treatment  of  the  patient,  we  may  secure  a  lower  mortality. 

This  is  cei-tainly  a  task  to  which  the  profession  should  seriously  address 
attention;  for  if  the  primary  mortality  of  the  extended  operation  for  car- 
cinoma of  the  uterus  can  be  reduced,  there  is  no  cjuestion  that  the  operation 
will  receive  general  favor,  and  that  the  proportion  of  women  ultimately  and 
permanently  cured  of  this  disease  by  the  ojierative  treatment  will  be  materi- 
ally increased  from  year  to  year. 

The  agitation  in  favor  of  early  diagnosis  and  operative  treatment  must 
still  be  continued.  LTnfortunately,  it  has  not  as  yet  had  the  effect  that  we 
might  have  expected.  In  the  majority  of  American  clinics  the  experience, 
I  think,  will  l)e  about  that  of  Reuben  Peterson  recently  in  Ann  Arbor,  where 
in  one  hundred  and  twenty-four  cancers  of  the  uterus,  seen  in  four  years, 
ninety-four  were  inoperable  when  the  i)atient  came  to  the  clinic.  The 
operability  is  in  direct  proportion  to  the  intelligence  and  social  status  of 
the  patient.    In  a  twenty-year  service  in  the  Philadelphia  Hospital,  not  a 


HYSTERECTOMY  201 

single  operable  case  was  admitted  to  the  ward  set  aside  for  such  cases, 
though  this  ward  was  constantly  filled  with  incurable  cases. 

Pregnancy  Complicating  Cancer  of  the  Uterus. — This  complica- 
tion is  fortunately  rare,  for  it  makes  the  operation  decidedly  more  difficult. 
In  57,833  labors  it  was  observed  but  twenty-six  times.  If  operable,  the 
cancer  should  be  removed  by  hj'sterectomy  without  regard  for  the  foetus. 
If  inoperable,  csesarean  section  after  the  foetus  is  viable  is  the  proper  proced- 
ure. I  have  done  three  panhysterectomies  in  early  pregnancy  and  one  at 
term,  coincident  with  a  csesarean  section.  The  extended  operation  was  done 
in  each  instance,  but  was  particularly  difficult  on  account  of  the  extra  blood 
supply  and  the  difficulty  of  haemostasis. 

Cuneiform  Hysterectomy  at  the  Fundus  or  the  Cornua. — This 
procedure  may  be  required  for  localized  streptococcic  infection,  or  may  be 
required  in  interstitial  pregnancy;  or  in  cases  of  salpingitis  isthmica  nodosa. 
After  excision  of  the  wedge-shaped  piece  to  remove  the  diseased  area,  the 
wound  is  brought  together  with  interrujited  sutures  in  the  myometrium, 
and  the  perimetrium  is  joined  by  a  continuous  suture  or  a  lace  suture,  that 
is,  a  continuous  suture  doubling  back  on  itself. 

The  principle  of  the  operation  is  naturally  to  remove  only  the  diseased 
area  and  no  more.  Haemostasis  may  be  difficult,  and  it  may  be  necessary 
to  ligate  the  vessels  separately;  but  ordinarily  the  hemorrhage  is  controlled 
by  the  sutures  which  unite  the  wound.  With  the  cuneiform  hysterectomy 
on  the  posterior  uterine  wall  for  the  correction  of  antiflexion,  I  have  had  no 
experience;  and  the  operation  has  not  seemed  to  me  a  logical  one,  the  anti- 
flexion  being  an  expression  of  undevelopment  which  the  cuneiform  hysterec- 
tomy cannot  be  expected  to  correct. 

A  wedge-shaped  excision  of  the  anterior  wall,  ruiming  the  whole  length 
of  the  uterine  body,  is  a  very  useful  procedure  in  cases  of  interposition,  in 
which  the  bulk  of  the  uterus  is  too  large  to  allow  it  to  be  placed  conveniently 
below  the  bladder.  Every  surgeon  with  much  experience  in  the  interposition 
operation  has  had  to  resort  to  this  form  of  cuneiform  hysterectomy  quite 
frequently. 

An  ingenious  procedure  proposed,  ad\ocated,  and  extensively  performed 
by  Shropshire,  of  San  Antonio,  Texas,  is  to  exsect  a  wedge  from  the  centre  of 
the  uterine  bodJ^  involving  both  anterior  and  posterior  wall  in  such  a  man- 
ner as  to  remove  the  entire  endometrium.  There  are  quite  a  number  of 
ca.ses  in  which  this  procedure  is  to  be  recommended — such  as  nienorrhagia, 
chronic  metritis,  and  endometritis;  and  in  the  case  of  women  in  whom  there 
might  be  a  suspicion,  not  actually  confirmed,  of  beginning  malignant  degen- 
eration of  the  endometrium. 

In  the  removal  of  the  tube  for  pyosalpinx,  when  it  is  possible  to  leave 
the  ovaries  behind,  this  operation  might  be  preferred  to  supravaginal 
hysterectomy. 


PLATE  CXXIX. 


Wertheim  or  extended  panhysterectomy. 


PLATE   CXXX. 


14 


Self-retaining  retractor  in  place  and  intestines  protected  by  gauzr  pad. 


PLATE  CXXXl. 


Self-retaining  retractor  adjusted.      Ovarian  and  round  ligament  arteries  clamped— anterior  base  of  broad  ligament  incised. 


PLATE  CXXXII. 


Uterine  artery  clamped  and  ureter  exposed. 


PLATE  CXXXIII. 


Wertheim  clamps  adjusted  and  vagina  severed  below  the  cervix. 


HYSTERECTOMY  207 

Supravaginal  Extraperitoneal  Hysterectomy  by  the  \'aginal 
Route. — I  have  found  this  an  extremely  useful  procedure,  and  have  utilized 
it  in  many  cases  since  first  seeing  it  performed  by  Doderlein,  of  Munich. 
(Plates  CXXXIV-CXLII.)  In  cases  of  chronic  metritis  or  endometritis 
near  the  menopause,  this  operation  has  a  large  field.  I  find  myself  often 
combining  it  with  an  interposition,  using  the  stump  of  the  broad  ligament 
tied  separately  in  three  sections  and  then  joined  in  the  middle  to  support 
the  bladder  instead  of  the  body  of  the  uterus  as  is  usually  done. 

The  technic  of  this  operation,  up  to  the  point  where  the  uterus  is  de- 
livered through  the  anterior  vaginal  vault,  is  exactly  the  same  as  the  inter- 
position operation;  but,  as  soon  as  the  body  of  the  uterus  is  delivered 
through  the  wound,  the  parietal  peritoneum  is  sutured  to  the  peritoneum 
of  the  posterior  uterine  wall  at  the  le\'el  of  the  internal  os.  From  this 
moment  the  operation  becomes  an  extraperitoneal  one;  the  broad  ligaments 
are  then  seized  with  clamps  in  three  successive  grips  and  are  severed  to  the 
level  of  the  internal  os.  Three  ligatures  are  placed  on  each  broad  ligament 
to  the  outer  side  of  the  clamps,  which  are  then  removed.  The  uterine 
body  is  then  cut  off  Ijy  an  incision  across  the  junction  of  the  body  with  the 
cervix;  the  wound  thus  left  in  the  latter  is  united  with  interrupted  sutures 
and  the  vaginal  wound  is  then  closed  over  it. 

For  all  external  appearances  the  woman  remains  as  she  was  before 
the  operation,  but  the  corpus  uteri  has  been  completely  removed,  leaving, 
as  a  rule,  only  the  appendages  and  cervix  behind. 

The  convalescence  of  these  patients  is  like  that  of  a  plastic  operation. 
It  is  surprising  to  see  how  little  reaction  follows  the  removal  of  the  uterine 
body  by  this  method. 


PLATE  CXXXIV. 


Supravaginal  extraperitoneni  liysterectomy. 


PLATE  CXXXV. 


Uterovesical  ligament  cut. 


PLATE  CXXXVI. 


Anterior  peritoneal  reduplication  opencil. 


PLATE  CXXXVII. 


Uterus  extracted — broad  ligaments  cut  and  ligated. 


PLATE.  CXXXVin. 


Peritoneum  sewed  to  posterior  wall    of  uterus. 


PLATE  CXXXIX 


Uterus  amputated. 


PLATE  CXT.. 


Cervical  wound  closed. 


PLATE  CXM. 


Closure  ot  wound  completed. 


PLATE  CXLII. 


Vaginal  mucous  membrane  united. 


HYSTERECTOMY  -217 

Vaginal  Hysterectomy. — Finally,  this  sul:)ject  remains  to  be  con- 
sidered (Plates  CXLIII-CXLVIII).  This  was  the  operation  of  choice  and 
the  one  uniformly  selected  a  generation  ago  for  the  removal  of  the  uterus; 
but  it  is  now  comparati\'ely  seldom  employed.  There  remains,  h()we\-er, 
a  distinct  field  for  it,  and  every  surgeon  of  nmch  experience  is  resorting  to  it 
from  time  to  time.  If  the  surgeon  follows  Goffe  or  the  Mayos  in  removing 
the  uterus  for  prolapse  and  cystocele,  this  operation  will  naturally  be 
frequently  employed ;  but,  personally,  I  do  not  see  the  necessity  for  the  re- 
moval of  the  uterus  for  these  conditions.  In  fact,  they  can  be  much  better 
dealt  with  in  another  way.  Personally,  I  employ  \-aginal  hysterectomy  for 
certain  unusual  cases  of  malignancy  and  for  fibrosis  of  the  uterus — and  for 
little  else,  although  occasionally  it  will  appear  that  this  method  of  removing 
the  womb  has  advantages  over  the  abdominal  operation.  For  example,  in 
very  fat  women  with  weak  hearts  and  a  decided  relaxation  of  the  vaginal 
outlet  and  the  vagina,  vaginal  hysterectomy  has  distinct  advantages  o\er 
the  abdominal  operation;  as  the  risk  in  such  cases  is  less,  and  there  is  decid- 
edly less  danger  of  heart  failure  from  the  prolonged  use  of  the  Trendelenburg 
position.  In  performing  this  operation  I  prefer  the  bisection  of  the  uterus, 
after  opening  both  the  anterior  and  the  posterior  vaginal  vault  and  laterally 
severing  the  attachment  of  the  vaginal  wall  to  the  cervix.  It  is  much  easier 
to  remove  one-half  the  uterus  at  a  time  than  it  is  to  take  out  the  whole 
organ  at  once.  This  is  particularly  true  of  cases  in  which  it  is  desired  to 
remove  the  appendages  comjiletely  with  the  uterus,  and  these  cases  consti- 
tute the  majority  in  my  practice. 

The  extended  operation  for  cancer  as  practised  in  Schauta's  clinic  does 
not  appeal  to  me.  The  technical  difficulties  are  great  and  (in  common  with 
most  surgeons,  I  think)  I  distinctly  prefer  Wertheim's  extended  operation 
l)y  the  abdominal  route.  But,  occasionally,  the  Schauta  operation  is  worth 
bearing  in  mind.  It  must  be  prefaced  by  a  deep  Schuchardt  incision  of  the 
vagina,  and  this  is  followed  by  a  dissection  of  the  parametrium  until  the 
whole  course  of  the  ureter  is  displayed  as  it  runs  across  the  base  of  the  broad 
ligament.  In  this  way  an  expert  with  this  operation  is  able  to  remove  about 
as  much  parametrium  as  can  be  done  by  the  Wertheim  operation;  but  this 
technic  does  not  permit  an  examination  of  the  pelvic  connective  tissue,  and 
it  might  easily  result  in  oA'erlooking  infected  glands  too  high  to  be  felt  in- 
seen  through  the  vaginal  wound. 

In  securing  the  broad  ligament,  in  a  xaginal  hysterectomy,  the  ligature 
method  is  distinctly  preferable.  In  the  early  part  of  my  practice,  almost 
every  surgeon  used  clamps  on  the  broad  ligament,  which  were  allowed  to 
remain  in  place  for  about  thirty-six  hours.  This  is  nmch  the  quickest  and 
easiest  method  for  performing  \aginal  hysterectomy;  but  so  many  disad- 
vantages were  discovered  in  it,  by  extended  experience,   that   \ery    few 


218  ATLAS  OF  OPERATIVE  GYN.ECOEOGY 

surgeons  to-day  resort  to  it.  Infection  of  the  peritoneal  cavity,  ])rolapse  of 
the  intestines,  fatal  obstruction  of  the  bowel,  and  occlusion  of  the  ureters 
were  quite  conunon  complications  of  the  old  method  of  performinji  vaginal 
hysterectomy. 

In  the  ligature  method,  it  is  convenient  to  cini)loy  tiic  clamps  (primarily 
about  three  in  number)  on  each  broad  ligament ;  and  then  to  ligate  the  liga- 
ment in  corresponding  sections,  the  ligature  being  passed  through  the  broad 
ligament  on  the  lateral  side  of  the  clamp;  and,  as  it  is  tied,  the  clamp  is 
loosened  so  as  to  allow  the  ligatures  to  l)ite  firmly  into  the  tissues.  The 
.stump  is  immediately  seized  again  with  a  clam]!  so  that  it  shall  not  retract 
out  of  reach,  a  very  awkward  accident  in  case  the  ligature  has  not  l)een 
firmly  enough  tied  and  hemorrhage  results.  After  each  broad  ligament  has 
been  ligated  in  the  manner  described,  the  sections  are  brought  downward 
into  the  opening  of  the  \-aginal  vault  and  are  stitched  across  in  a  row  by 
sutures  that  include  the  anterior  anil  ]iosterior  vaginal  walls  at  the  fornix. 
In  this  manner  the  stumjis  are  secured  in  a  position  where  they  are  reatlily 
reached,  and  by  their  bulk  they  close  the  aperture  into  the  peritoneal  cavity, 
thus  preventing  prolapse  and  adhesion  of  the  intestinal  coils.  The  parietal 
peritoneum,  both  anterior  and  posterior,  is  also  caught  in  the  sutures  run- 
ning through  the  vaginal  wall  and  the  stumps  of  the  broad  ligament.  In 
this  manner,  the  opening  from  above  is  satisfactorily  and  easily  peritoneal- 
ized.  Extra  sutures  are  used,  when  recjuired,  to  check  the  hemorrhage  from 
the  cut  surfaces  of  the  ^'aginal  wall,  and,  at  the  same  time,  to  close  more 
completely  the  \aginal  wound.  At  the  conclusion  of  the  operation,  the  vagina 
is  packed  with  sterile  gauze  which  is  allowed  to  remain  in  place  twenty-four 
to  forty-eight  hours. 

I  make  it  a  rule  never  to  attempt  a  vaginal  hysterectomy  unless  the 
abdomen  is  prepared  for  an  immediate  section.  For,  occasionally,  insuper- 
able difficvdties  are  encountered  in  the  operation.  Or  else  a  hemorrhage 
may  occasionally  occur  which  can  only  be  controlled  from  above  through  an 
abdominal  incision. 

A  number  of  years  ago,  l)efore  the  necessity  for  this  precaution  was 
universally  recognized,  I  witnessed  deaths  in  the  hands  of  some  of  my 
colleagiies  on  account  of  the  hurried  performance  of  an  abdominal  section 
without  adequate  preparation  of  the  patient.  Of  late  years,  however,  I 
have  not  seen  nor  heard  of  such  a  thing. 


PLATE  CXLIII. 


15 


Vaginal  hysterectomy. 


PLATE  CXLIV. 


Dividing  the  uterus. 


PLATE  CXLV. 


Discission  of  uterus  carried  to  fundus. 


PLATE  CXLVI. 


Anterior  wall  and  fundus  divided.    Posterior  vaginal  vault  opened  and  vagina  separated  from  cervix. 


PLATE  CXLVII. 


Arteries  and  broad  ligament  clamped  and  tied. 


PLATE  CXLVIIl. 


T\vi)  linhcji  of  uterus  removed — broad  ligaiueiit  tied  in  three  segments.    Stump  to  be  sutured  together. 


CESAREAN  SECTION  <i-25 

CiESAREAN  SECTION 

The  modern  operation  had  its  beginning,  in  isTti,  with  the  proixhsition 
of  Porro  to  perform  a  supravaginal  amputation  of  the  uterus  after  its 
evacuation,  with  an  extraperitoneal  fixation  of  the  stump.  As  is  well- 
known,  the  almost  incredible  mortality  of  the  operation  before  Porro's 
time,  due  to  failure  to  suture  the  uterine  wound,  nearly  excluded  this 
procedure  from  legitimate  surgery. 

Six  years  later  came  the  proposition  of  Saenger  to  suture  the  uterine 
wound — although  this  had  been  done  before,  in  single  instances,  both  in 
Europe  and  America.  With  the  steady  improvement  of  operative  and 
antiseptic  technic,  the  result  of  the  operation  has  correspondingly  improved, 
until  it  is  now  one  of  the  most  satisfactory  in  abdominal  surgery.  Its 
facility,  dramatic  character,  and  successful  results  now  in\ite  an  al)use  of 
the  operation — a  strange  contrast  with  the  feeling  entertained  toward  it  by 
a  former  generation  of  physicians. 

The  modern  operator  must  be  pre])ared  to  select  one  of  se\-eral  \-arieties 
of  csesarean  section:  the  so-called  conservative  operation  of  Saenger,  with 
suture  of  the  uterine  wound,  the  supravaginal  amputation  of  the  uterus, 
peritonealization  and  sinking  of  the  cervical  stmnp;  the  supravaginal  ampu- 
tation of  the  uterus,  with  extraperitoneal  fixation  of  the  cer\ical  stump; 
panhysterectomy,  after  the  evacuation  of  the  uterus;  and  some  form  of 
extraperitoneal  csesarean  section  in  presumably  infected  cases. 

Conservative  Cesarean  Section. — The  case  best  suited  for  this 
form  of  section  is  a  woman  in  the  first  stage  of  labor  who  has  not  been 
examined,  and  before  the  ruptiu'e  of  the  membranes  or  even  before  labor 
has  begim;  the  operation  being  imdertaken,  like  any  other  abdominal 
section,  at  an  appointed  time  and  with  adequate  preparation.  The  result, 
however,  does  not  depend  so  much  on  the  length  of  time  that  the  woman 
has  been  in  labor  (as  claimed  by  Rejmolds  and  Williams)  as  it  does  upon 
the  number  of  examinations  and  the  manner  in  which  they  have  been  made. 
]\Iy  results,  in  cases  subjected  to  the  test  of  labor  lasting  twentj^-fom-  hours 
in  a  primipara  and  twelve  hours  in  a  nuiltiimra,  have  been  just  as  good  as 
in  operations  performed  before  labor  began  or  in  its  earliest  stages.  But 
all  these  cases  have  been  under  my  personal  supervision,  and  the  few  exami- 
nations that  have  been  made  have  been  conducted  with  a  scruinilously 
careful  aseptic  technic.  The  method  of  performing  the  operation  is  as 
follows : 

An  incision  is  made  through  the  al)d(nninal  wall,  alxmt  one-third  al)ove 
the  umbilicus  and  two-thirds  below,  measuring  not  more  than  four  inches  in 
length,  or  just  sufficient  to  allow  the  extraction  of  the  fetal  head  (Plate 
CXLIX).  The  uterus  is  then  pushed  from  the  right  side  of  the  woman's 
abdomen  toward  the  left,  in  order  to  counteract  the  normal  right  tilting  of 


2^26  ATLAS  OF  OPERATIVE  GYN/ECOLOGY 

the  pregnant  uterus  and  to  l)ring  the  uterine  incision  in  the  midhne  of  the 
uterine  body,  where  the  hemorrhage  will  be  least.  This  precaution  has 
another  advantage  in  preventing  a  coincidence  of  tlic  uterine  and  abdominal 
woun<ls  during  ])uerperal  convalescence;  for  the  uterus  resumes  its  right  tilt 
again  after  the  completion  of  the  operation,  bringing  the  uterine  wounil  out 
of  line  with  the  abdominal  wound  and  thus  accomplishing  the  same  result 
secured  by  Asa  Davis's  proposition  to  make  the  abdominal  incision  entirely 
above  the  innbilicus.  The  lower  incision  which  I  advocate  has  the  great 
advantage  of  making  the  uterine  suture  much  easier  than  if  the  abdominal 
incision  is  entirely  above  tlie  umbilicus;  for  through  this  lower  incision  the 
uteiTis,  after  its  evacuation,  can  be  eventrated  and  tlie  sutiu'ing  can  be 
conducted  conveniently  outside  the  abdominal  cavity. 

The  uterine  wound,  corresponding  in  length  with  the  abdominal  wound, 
having  opened  the  uterine  cavity,  an  assistant  compresses  the  abdominal 
walls  ujion  the  uterus  as  the  membranes  are  rujitured.  The  operator  then 
seeks  for  and  seizes  one  foot  of  the  fa>tus,  lij'  which  it  is  extracted;  and  as 
the  head  emerges  from  the  uterine  wound  the  assistant,  hooking  his  finger 
in  the  upper  angle  of  the  wound,  pulls  the  uterus  outside  the  woman's 
abdominal  cavity.  Immediately  a  broad  soft  gauze  pad  is  tucked  behind 
the  uterus,  covering  the  intestines  and  preventing  their  escape. 

The  placenta  is  then  separated  and  great  care  is  exercised  to  separate 
com])l(>tely  and  to  extract  all  of  the  membrane — which  can  best  be  accom- 
plished by  seizing  succe.ssive  layers  or  portions  of  the  membrane  with  a 
long  curved  hiemostatic  forceps  of  the  Keen  model. 

The  uterine  cavity  being  completely  evacuated,  the  suture  of  the  uterine 
wall  is  made  as  follows,  by  a  method  which  I  have  adopted  after  experiment- 
ing with  a  number  of  others  and  witnessing  various  kintls  of  uterine  closure 
in  other  clinics:  Three  sutures  of  fine  linen  thread  are  inserted  through  the 
myometrium,  each  end  being  caught  by  a  hai-mostat  and  laid  aside  (Plate 
C'L).  Next  a  running  suture  of  number  2  chromic  catgut  begins  above  the 
u])per  angle  of  the  uterine  wound  (Plate  CLI),  then  runs  down  the  deeper 
])(iition  of  the  myometrium,  axoiding  the  endometrium,  and  comes  up  more 
su]u>rficially,  the  suture  ending  ojij^osite  whei'e  it  began  with  a  knot  above 
the  upper  angle  of  the  uterine  wound  upon  the  surface  of  the  uterus.  The 
two  sutures  of  linen  thread  are  then  tied  as  interrupted  sutures  (Plate  CLII) . 
Finally,  a  laced  suture  unites  the  perimetrium  (Plate  CLIII),  running  down 
as  a  continuous  suture  and  coming  up  as  a  continuous  suture  with  the  inser- 
tion of  the  needle  coming  up  midway  between  the  insertions  made  going 
down;  the  suture  ending  in  a  knot  above  the  upper  angle  of  the  wound  on 
the  surface  of  the  uterus  (Plate  CLIV). 

While  the  abdominal  incision  is  being  made,  the  patient  receives  hypo- 
dermatically  a  whole  ampoule  of  pituitary  extract  and  an  ampoule  of  ergo- 


CESAREAN  SECTION  227 

tine.  If  there  is  a  tendency  to  uterine  relaxation  and  to  hemorrhage  during 
the  operation,  a  second  ampoule  of  ergotine  is  administered.  The  abdominal 
wound  is  closed  in  the  usual  manner,  is  sealed  by  strips  of  gauze  and  collo- 
dium,  and  the  dressing  (a  gauze  pad  and  a  couple  of  adhesive  straps)  is 
applied  very  lightly  over  the  sealed  abdominal  wound,  in  order  not  to  exert 
any  pressure  against  the  uterine  body.  The  patient  is  not  kept  rigidly  upon 
her  back,  but  is  rather  encouraged  to  turn,  with  the  aid  of  a  nurse,  partly 
on  one  side  and  then  upon  the  other — in  this  way  a\'oiding,  as  a  rule,  an 
adhesion  of  the  uterine  to  the  abdominal  wall.  The  after-treatment  is  the 
same  as  after  any  abdominal  section.  With  this  method  of  uterine  suture, 
in  more  than  three  hundred  csesarean  sections,  I  have  not  seen  (nor  has 
there  been  reported  to  me)  a  case  of  rupture  of  the  uterine  wound  in  subse- 
quent pregnancies  and  labors,  although  the  percentage  of  this  accident  has 
been  found  to  be  about  three  by  some  statistical  investigators. 


PLATE  CXM\. 


Size  and  site  of  tibduriiiii;il  incision. 


PLATE  CL. 


The  infant    and   plucenta   have  been  extracted.     The  empty   uterus  is  eventrated.     Three  sutures  of  fine  linen   thread    are 

placed  in  the  myometrium. 


PLATE  CLI, 


The  myometrium  is  united  with  a  two-tier  number  2  chromic  catgut  suture. 


PLATE  CLII. 


The  two-tier'fluture  is  finished,  but  in  the  drawing   the   upper  layer   (in  order  to  show  it)    is  not  drawn  tight. 

The  lineD  threadfl  are  now  tied. 


PLATE  CLIII 


A  laced  suture  of  number  2  chromic  catgut  unites  the  perimetrium. 


PLATE  CLIV. 


The  perimetrium  stitch  complete. 


234  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

The  Porro  Operation. — (Supravaginal  Amputation  of  the  Uterus 
with  Peritonealizalion  and  Sinking  of  the  Cervical  Stump.)  The  only  indica- 
tion that  I  have  found  for  this  operation,  of  late  years,  is  the  existence  of 
fibroinyomata  as  an  obstruction  in  labor,  or  as  a  complication  of  pregnancy 
or  labor  recjuiring  cesarean  section  and  infiltration  of  the  myometrium 
with  blood  in  premature  detachment  of  the  placenta.  In  the  earlier  part 
of  my  practice  I  performed  more  amputations  of  the  uterus  in  caesarean 
sections  than  I  did  Saenger  operations. 

The  technic  of  this  operation  is  the  same,  up  to  the  point  where  the 
uterus  is  evacuated;  except  that  the  abdominal  incision  is  made  somewhat 
lower,  in  order  to  facilitate  the  closure  of  the  cervical  stump.  The  uterus  is 
then  amputated  as  in  any  supravaginal  amputation — for  instance,  one  for  a 
fibroid  tumor;  the  vessels  are  clamped  and  cut  and  the  stump  and  broad 
ligaments  sewed  over  in  the  manner  already  described.  If  it  is  desired  to 
leave  the  ovaries,  the  tubes  should  also  remain  to  les.sen  the  danger  of 
degeneration  of  the  ovaries;  in  this  case,  the  broad  ligaments  are  sewed 
together  in  the  midline  over  the  cervical  stump,  instead  of  being  sewed 
from  one  side  of  the  pelvic  ca\-ity  to  the  other. 

Particular  care  must  he  exercised  to  close  the  cerv'ical  stump  itself  by 
interrupted  anteroposterior  catgut  .sutures;  otherwise  there  will  be  trouble- 
some oozing — the  formation  of  a  hsematoma  under  the  peritoneal  flap,  with 
possible  infection,  and  \\ith  a  distinct  increase  of  danger  to  the  patient. 

Supravaginal  Amput.\tion  of  the  Uteris  with  Extraperitoneal 
Fixation  of  the  Cervical  Sti  mp. — This  form  of  operation  I  have  found 
most  useful  in  the  severest  infections,  which  are  brought  into  the  hospital 
after  repeated  attempts  at  forceps  delivery  and  a  number  of  examinations 
made  without  aseptic  precaution. 

As  an  example,  a  case  was  admitted  to  my  ser\-ice  in  which,  after 
several  days  of  labor,  three  physicians  in  succession  had  applied  forceps, 
and  in  the  intervals  between  their  tractive  efforts  had  laid  the  forceps  on  a 
wooden  floor  covered  with  dust  and  then  had  inserted  them  in  the  uterus 
without  an}'  attempt  to  cleanse  them.  The  odor  from  the  genital  tract  was 
horribly  putrid.  In  the  course  of  the  operation  a  slight  wound  that  I  made 
in  one  of  mj-  fingers  laid  me  up  for  several  weeks  with  severe  infection. 
After  the  removal  of  the  uterus,  the  stench  was  so  intolerable  that  it  was 
immediately  taken  out  of  the  operating  room.    This  woman  recovered. 

The  technic  of  such  an  operation  is  as  follows:  The  uterus  is  delivered 
unopened  out  of  the  woman's  abdomen  through  a  long  abdominal  incision. 
The  intestines  are  then  carefully  packed  ofT  with  gauze  pads;  the  broad 
ligaments  are  clamped,  cut,  and  ligated  to  the  uterine  arteries,  which  are 
then  clamped  and  ligated  separately.  The  cut  edges  of  the  broad  ligaments 
are  united.    The  parietal  peritoneum  is  then  sewed  closely  around  the  cervix. 


CESAREAN  SECTION  235 

and  the  uterus  is  amputated  with  a  cautery  knife  without  being  opened  at  all. 
Should  the  baby  be  alive,  the  operation  is  conducted  as  quickly  as  possible, 
and  the  child  is  extracted  immediately  from  the  uterus  as  soon  as  it  is  ampu- 
tated; but  in  almost  all  of  these  cases  the  child  is  dead  before  the  operation 
is  attempted.  After  the  amputation  of  the  uterus,  the  myometrium  of  the 
cervix  is  carefully  sutured  by  interrupted  catgut  sutures  to  prevent  oozing; 
the  peritoneum  is  closed  over  it,  and  the  stump  is  then  allowed  to  drop  back 
as  far  as  its  peritoneal  investiture  will  permit.  The  sinus  remaining  after 
the  abdominal  wall  is  closed  above  the  retracted  cervix  is  packed  lightly 
with  a  strip  of  gauze. 

This  operative  technic  is  I  think  easier,  quicker,  and  safer  than  a  pan- 
hysterectomy. The  amputation  of  the  cervix  with  a  cautery  knife  and  the 
immediate  closure  of  the  cervical  myometrium  avoids  opening  an  infected 
vagina  into  the  peritoneal  cavity;  and  I  feel  convinced  that  it  will  give  in  a 
series  of  cases  a  better  result  than  the  total  removal  of  the  uterus.  This  has 
certainly  been  my  experience;  as,  in  the  limited  nmnber  of  cavses  in  which 
I  have  carried  out  this  technic,  there  has  been  a  uniform  maternal  recovery. 

Panhysterectomy  w^th  Cesarean  Section. — The  only  indication 
which  I  have  found  for  this  operation  is  a  coincident  cancer  of  the  cervix 
with  delivery  by  ca'sarean  section  at  term.  The  operation  is  not  a  particu- 
larly difficult  one,  except  for  the  difficulty  of  controling  hemorrhage  deep 
in  the  pelvis  at  the  angles  of  the  vaginal  wound.  The  operation  is  conducted 
pretty  much  in  the  same  manner  as  the  Wertheim  or  extended  panhysterec- 
tomy for  cancer  in  the  non-pregnant  uterus.  With  the  much  hj-pertrophied 
blood-vessels  and  IjTnphatics  it  would  seem  likely  that  recurrence  is  more 
probable  than  after  a  panhysterectomy  in  a  non-pregnant  uterus.  In  an 
operation  of  this  sort  successfully  performed  within  a  year  there  was  a 
recurrence  at  the  vaginal  vault  within  six  months  which  is  now  being  treated 
by  radium,  but  1  fear  unsuccessfully. 

Extraperitoneal  Cesarean  Section. — Since  the  revival  by  Frank 
of  the  old  idea  of  extraperitoneal  ca?sarean  section  in  presumably  infected 
cases,  the  operation  has  received  an  extensive  enough  trial  to  warrant 
definite  conclusions  as  to  its  worth. 

If  one  studies  the  statistics  collected  by  Routh,  in  Great  Britain,  of  the 
results  of  cesarean  section  in  presumably  infected  cases,  and  compares 
these  results  \\i{\\  those  of  extraperitoneal  csesarean  section  in  Germany,  in 
the  same  class  of  cases,  there  can  be  no  doubt  of  the  superiority  of  the  latter 
operation  over  the  conservative  intra-abdominal  or  intraperitoneal  operation. 

The  Routh  statistics  show  a  mortality  of  more  than  seventeen  per 
cent.,  while  the  average  statistics  of  the  German  operators  give  a  mortality 
of  but  six  per  cent,  in  the  same  class  of  cases.  It  should  be  apparent,  there- 
fore, that  a  patient  must  receive  the  added  chance  for  hfe  wliich  an  extra- 

16 


>;?6  ATLAS  OF  OPERATIVE  G\'N.ECOLOGY 

peritoneal  caesarean  section  assures  her,  if  the  surgeon  is  to  do  his  full  duty 
to  her. 

There  has  been  a  strange  indisposition  on  the  part  of  American  special- 
ists in  obstetrics  to  take  up  extraperitoneal  csesarean  section — explained, 
I  think,  by  the  fact  that  too  many  professed  experts  in  olistetrics  in  America 
are  not  well  trained  as  surgeons. 

The  technical  difficulties  of  the  operation  as  compared  with  the  older 
method  has,  I  believe,  deterred  many  a  specialist  from  attempting  it;  and 
there  has  been  a  disposition  to  excuse  this  disinclination  to  attempt  a  new 
operation  on  the  .ground  that  it  did  not  yield  sufficiently  good  results  to 
justify  it;  but  this  assumption  is  unwarranted. 

Everyone  who  has  gi\en  extraperitoneal  c:esarean  section  a  fair  trial 
remains  convinced,  I  am  sure,  of  its  applicability  to  the  kind  of  case  for 
which  it  was  devised.  In  my  own  experience,  thirty  extraperitoneal  csesar- 
ean sections  ha^•e  been  performed  without  any  maternal  mortality,  although 
the  operation  has  been  reserved  in  my  hospital  services  for  cases  which 
come  to  me  almost  certainly  infected — cases  examined  repeatedly  outside 
without  careful  aseptic  technic,  and  cases  in  which  futile  attempts  have  been 
made  to  deliver  with  forcejis. 

After  trying  several  methods,  I  have  for  the  last  four  years  resorted 
to  a  technic  which  I  had  at  first  thought  to  be  original,  but  which  I  subse- 
quently discovered  to  have  been  devised  by  Veit  and  Fromme.  This 
method  is  comparatively  simple;  and  the  result  has  proved  (in  my  experi- 
ence) that  it  is  reliable,  jtreventing  infection  of  the  peritoneal  cavity — 
especially  during  puerperal  convalescence,  which  is  the  chief  danger  of 
caesarean  section  performed  upon  the  presumably  infected  woman,  the 
infection  of  the  endometrium  in  such  cases  spreading  directly  through  the 
uterine  wound  to  the  peritoneal  surface  and  rapidly  causing  a  general  septic 
peritonitis. 

The  technic  I  have  fovmd  most  satisfactory,  after  trying  other  plans, 
is  as  follows : 

An  incision  through  the  abdonunal  wall  is  made  from  a  short  distance 
below  the  umbilicus  down  to  the  symphysis  pubis  (Plates  CLV-CVII). 
The  parietal  peritoneum  is  severed  to  the  fundus  of  the  bladder.  The  loose 
peritoneum  over  the  lower  uterine  segment  is  then  lifted  with  hsemostats 
and  incised  with  a  short  incision;  closed  scissors  are  inserted  in  the  incision 
and  pushed  upward  as  far  as  the  peritoneum  can  be  detached  from  the  uter- 
ine wall.  The  incision  in  the  uterine  peritoneum  is  then  lengthened  to  this 
extent  upward.  It  is  then  carried  downward  to  its  reduplication  over  the 
bladder,  opening  the  uterovesical  space;  an  abdominal  retractor  is  then 
inserted  over  the  symphysis  pubis  in  such  a  manner  as  to  crowd  the  bladder 
downward  and  forward.     The  uterine  wall  is  then  incised;  the   incision 


CESAREAN  SECTION  237 

beginning  at  the  upper  angle  of  the  incision  in  the  uterine  peritoneum;  it  is 
carried  downward  then  in  the  middle  hne  with  scissors,  as  low  as  possible, 
extending  a  considerable  distance  below  the  uterovesical  reduplication  of 
the  ]ieritoneum.  ^leanwhile  an  assistant  clamps  the  peritoneum  of  the 
uterus  to  the  peritoneum  of  the  abdominal  wall  with  T-shaped  hannostats 
in  order  to  close  off  the  peritoneal  ca\aty  (Plate  CLVIII). 

If  the  fetal  head  is  presenting,  it  now  comes  plainly  into  view.  It  is 
seized  with  a  Simpson  obstetrical  forceps  inserted  through  the  uterine 
incision,  and  is  turned  out  of  the  uterine  cavity  by  a  lever-like  action  of 
the  forceps  handles  (Plate  CLIX). 

Sellheim  has  devised  a  special  scoop  for  this  purpose  which  he  uses 
very  skilfully;  but  after  one  or  two  trials  of  it  I  have  discarded  it,  finding 
the  forceps  much  more  satisfactory. 

The  placenta  is  then  detached  and  extracted;  the  membranes  are  next 
carefully  detached  so  that  none  shall  be  left  behind.  During  this  part  of 
the  operation  there  may  be  some  troublesome  hemorrhage  from  the  placental 
site.    There  is  rarely  much  hemorrhage  from  the  uterine  incision. 

If  the  labor  has  been  much  delayed  and  the  lower  uterine  segment  is 
much  distended,  it  is  surprising  to  see  how  little  bleeding  occurs  from  the 
thinned-out  uterine  wall.  After  the  extraction  of  the  placenta  and  mem- 
brane, the  uterine  incision  is  sutured  by  a  two-layer  continuous  catgut 
suture,  number  2  chromic  gut  being  preferred.  The  suture  runs  down  the 
deeper  portion  of  the  myometrium,  a\'oiding  the  endometrium,  and  returns 
superficially,  one  knot  being  tied  above  the  upper  angle  of  the  uterine 
wound.  It  is  usually  necessary  to  insert  a  few  interrupted  catgut  sutures 
superficial  to  the  two-tier  continued  suture,  in  order  to  secure  perfect  appo- 
sition of  the  superficial  layer  of  the  uterine  musculature.  The  space  behind 
and  below  the  bladder  is  then  carefully  cleansed  with  gauze  pads.  Next 
the  two  layers  of  peritoneum  are  closed  with  a  continuous  catgut  suture 
(Plate  C'LXI)  and  finally  the  conjoined  layers  of  peritoneum  are  joined 
together  in  the  middle  line  by  three  or  four  interrupted  catgut  sutures.  In 
this  way  the  uterine  wound  is  kept  completely  out  of  the  peritoneal  cavity 
and  there  is  a  complete  extraperitoneal  convalescence — the  most  important 
object  to  be  secured  by  this  operation. 

It  is  easy  enough  to  make  any  kind  of  a  csesarean  section  extraperi- 
toneal during  its  performance  by  eventrating  the  uterine  body;  but  it  is 
in  the  first  few  hours  after  the  performance  of  the  operation  that  infection 
through  the  uterine  wound  from  an  infected  endometrium  is  most  dangerous 
to  the  patient. 

In  my  early  operations  I  sutured  the  two  layers  of  peritoneum  together 
before  incising  the  ut-erus;  but  I  found  that  the  peritoneum  was  so  fre<iuently 
torn  during  the  extraction  of  the  child  that  I  was  obliged  to  resuture  the 


PLATE  CLVI. 


Incising  the  parietal  peritoneum. 


PLATE  CLVII. 


Incising  the  visceral  peritoneum  over  the  lower  uterine  segment  where  it  is  loose  and  detachable. 


PLATE  CLVIII. 


Thf  twu  l:iytMa  ul  peiitoneum  damped  together  with  T-clamps. 


PLATE   CI>X. 


llnldiiit;  tilt;  infant  face  (!■  iwnwanl  for  a  few  nionients  to  let  tlio  liquor   aninii   out   nf   the  tnnntli  aiul  hint 


PLATE  CLXI. 


Sewing  the  two  layers  of  peritoneum  together  to  make  the  convalesrenre  eitrsperitoneal. 


PLATE  CI.XII. 


The  suture  of  the  uterine  muscular  wall. 


,>46  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

peritoneum,  and  meanwhile  there  was  danger  of  contaminating  the  peri- 
toneal cavity.  It  is  much  better,  therefore,  to  close  off  the  peritoneal  cavity 
securely  by  clamps  during  the  operation  and  then  to  secure  a  perfect  closure 
by  sutures  after  the  uterine  wound  is  closed  and  after  the  uterus  has  con- 
tracted subsequent  tcj  its  evacuation. 

Injections  of  pituitary  extract  and  ergotine  are  given  at  this  operation, 
as  in  the  conservative  csesarean  section;  but  they  are  not  administered  until 
the  uterine  wound  ha.s  been  made  and  the  child's  head  is  extracted,  for  fear 
of  premature  rupture  of  the  distended  lower  uterine  segment. 

PUBIOTOMY 

Pubiotomy  was  designed  by  the  Italian  surgeon,  Gigli,  to  supplant 
symphysiotomy;  which,  after  a  checkered  career  of  more  than  a  century, 
is  now  scarcely  ever  heard  of. 

According  to  its  advocates,  pubiotomy  is  superior  to  symphysiotomy 
for  two  reasons:  (1)  is  does  not  interfere  with  the  supports  of  the  bladder  or 
urethra,  and  (2)  the  section  is  made  through  bone  instead  of  cartilage  and 
is  therefore,  it  is  claimed,  more  likely  to  heal  readily.  The  advocates  of 
pubiotomy  are,  as  a  rule,  obstetricians  who  have  not  yet  had  extensive  experi- 
ence in  abdominal  surgery.  Even  those  who  most  enthusiastically  endorse 
it  acknowledge  that  it  is  not  an  operation  for  the  occasional  operator; 
that  it  should  be  performed  only  in  women  who  show  no  signs  (jf  infec- 
tion; and  that  it  is  best  done  in  a  well-equipped  hospital.  Even  under  all 
these  circumstances  the  several  varieties  of  cesarean  section  are,  to  my 
mind,  much  superior. 

In  an  uninfected  case  no  surgeon  of  large  experience  with  both  opera- 
tions would  hesitate  to  make  a  choice  in  favor  of  an  abdominal  ca>sarean 
section.  The  best  statistics  of  the  latter  operation  are  quite  equal  or  superior 
to  the  best  statistics  of  pubiotomy  and  there  is  no  comparison  between  the 
convalescence  of  the  two  operations. 

In  csesarean  section,  also,  there  is  entire  freedom  from  the  disagreeable 
complications  which  not  infrequently  occur  in  pubiotomy — injury  of  the 
bladder;  lacerations  of  the  vagina;  making  a  compound  fracture  of  the  pelvis ; 
communicating  with  the  vaginal  canal,  with  impossibility  of  preventing 
infection  of  the  pelvic  bones.  There  is  rarely  a  bony  union  after  pubiotomy 
and  there  is  a  possibility,  therefore,  of  disability  in  the  patient's  future 
life  history. 

Occasionally  the  pelvis  may  be  found  slightly  enlarged  by  the  filjrous 
union  which  usually  takes  place  between  the  severed  ends  of  the  pubic  bone ; 
and  it  is  possible  that  subsequent  labors,  on  this  account,  may  be  spontane- 
ous, but  this  result  is  not  to  be  looked  for  and  only  rarely  occurs. 

Personally  I  am  convinced  that  pubiotomy  in  the  near  future  will  go 


PUBIOTOMY  247 

the  way  of  symphysiotomy,  from  which  it  differs  very  little  and  over  which 
it  has  few  advantages.    If,  however,  a  surgeon  should  feel  mchned  to  resort 
to  this  operation,  the  best  method  of  performing  it  is  Dcederlem  s  modifica- 
tion of  the  original  operation;  which  consists  in  makmg  a  small  mcision 
above  the  upper  edge  of  the  pubic  bone,  selecting  the  region  of  tbe  pubic 
spine  toward  which  the  occiput  of  the  child  is  directed.    ^^  hen    he  upper 
edge  of  the  bone  has  been  exposed,  the  periosteum  is  incised  and  hen   he 
needle  devised  by  Dcederlein  is  inserted  directly  behind  the  bone  and  guided 
downward  by  a  forefinger  until  its  tip  can  be  made  to  project  under  the  bone 
(Plates  CLXIII,  CLXIV).     At  this  point  the  skin  of  the  corresponding 
labium  is  drawn  toward  the  middle  Une  so  that  the  puncture  which  allows 
the  escape  of  the  point  of  the  needle  shall  be  as  far  removed  from  the  vulvar 
orifice  as  possible.    The  point  of  the  needle  being  now  pressed  outward  so 
as  to  make  a  projection  of  the  skin  over  it,  a  small  incision  is  made  so   hat 
the  needle  can  emerge;  the  end  of  a  Gigli  saw  is  then  attached  to  it,  and   he 
needle  is  withdrawn  upward  so  that  the  saw  is  placed  directly  behind  the 
pubic  bone;  a  few  to-and-fro  movements  of  the  saw,  to  which  theJiancUe  is 
now  attached,  severs  the  bone.    There  is  often  quite  free  hemorrhage  from 
both  upper  and  lower  wounds,  but  it  can  usually  be  controlled  by  pressure 
(altlK.ugh  a  fatal  bleeding  is  recorded).    After  the  bone  is  severed,  a  choice 
must  be  made  between  the  immediate  extraction  of  the  child  or  allowing 
it  to  be  spontaneously  expelled.    The  latter  course  seems  to  me    o  be    he 
safer  one;  for  the  application  of  forceps,  or  the  extraction  of  a  child  by  the 
foot  in  a  breech  presentation  is  much  more  likely  to  lacerate  the  vagina 
than  would  be  the  case  in  a  spontaneous  delivery.  x,,j  w„ 

In  the  Heidelberg  clinic  I  was  told  that  the  expectant  plan  had  been 
pursued-  and  if  I  remember  correctly  with  something  like  eighty  uninter- 
rupted recoveries,  so  far  as  primary  mortality  is  concernecl. 

The  morbiditv  after  pubiotomy  is  always  high,  much  higher  than  in 
convalescence  from  ca^sarean  section,  and  the  care  of  the  patient  during 
convalescence  is  extremely  troublesome.  ,     .     „     •        ,    , 

The  hips  should  be  supported  by  a  broad  band  of  adhesive  p  aster  or 
by  a  firm  bandage  which  buckles  together;  the  patient  shoul.l  he  on  a 
Bradford  frame.     It  is  exceedingly  difficult,  on  this  apparatus,  and  with 
the  constrained  posture  of  the  woman,  to  keep  her  clean,  to  cathetenze  he 
if  required,  and  to  give  her  the  attention  demanded  by  the  average  puei  pel  a 
convalescent.    If  it  is  desired  to  secure  Ix.ny  union  ot  the  pelvis,  the  patient 
must  be  kept  rigidly  quiet  for  two  or  three  weeks    but  it  the  operator  is 
satisfied  with  the  average  cartilaginous  union  and  the  chance  o    disakli 
in  the  patient's  future  life  history,  movement  can  be  allowed  attei    ^^o  oi 
three  days.    If  the  vagina  is  extensively  torn  in  deli^;ery  and  the  lacera- 
tion coninunicates  with  the  severed  ends  of  the  pelvic  bone,  the  most 


248  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

unfavorable  kind  of  compound  fracture  of  the  pelvis  results.  One  of  my 
patients  died  from  this  cause,  and  I  do  not  see  how  such  an  accident 
can  always  be  prevented. 

Another  exceedingly  disagreeable  possibility  which  I  once  encountered 
when  I  was  doing  symphysiotomy,  but  which  might  also  confront  the  oper- 
ator in  pubiotomy,  is  an  inability  to  extract  the  child  after  severing  the  pelvic 
bones  on  account  of  the  miscalculation  of  pelvic  size  or  of  the  size  of  the 
fetal  head. 

It  is  stated  by  the  advocates  of  pubiotomy  that  it  is  practicable  with  a 
pelvis  having  a  conjugate  diameter  down  to  7  cm. ;  Imt  everyone  knows  how 
difficult  it  is  to  make  an  absolutely  accurate  diagnosis  of  pelvic  size,  even 
with  instruments  of  precision  recently  devised  for  this  jiurpose.  ^Moreover, 
pelvic  measurements  are  only  relative  and  it  is  absolutely  impossible  by 
any  of  the  methods  of  antepartum  foetometry  to  make  an  accurate  estimate 
of  the  size  of  the  fetal  head. 

Antepartum  foetometry  enables  us  to  make  a  fairly  accurate  estimate 
of  the  size  of  the  infant,  but  a  miscalculation  is  always  perfectly  possible 
and  no  one  can  be  certain  of  avoiding  it. 

\Miile  the  specialists  who  practice  pubiotomy  have  recommended  that 
it  should  be  performed  only  by  experts  and  under  the  most  favorable  con- 
ditions, I  feel  that  the  operation  is  more  suitable  to  the  occasional  operator 
who  has  no  training  in  abdominal  surgery;  for  such  an  individual  it  is  a 
much  easier  oiH-ration  than  ca^sarean  section,  reciuiriug  fewer  implements 
and  not  demanding  such  expert  assistance.  But  with  the  excellent  training 
that  students  are  now  .securing  in  the  principles  of  abdominal  surgery,  and 
with  the  ample  opportunity  afforded  at  present  for  acciuiring  skill  in  this 
kind  of  work,  even  for  the  occasional  operator,  I  believe,  ciesarean  section 
in  the  future  will  ]irove  the  safer  and  more  desirable  procedure,  and  that 
pubiotomy  in  the  near  future  will  be  regarded  in  the  same  light  in  which 
symphysiotomy  is  regarded  to-day — as  an  operation  with  an  interesting 
history,  but  for  which  the  need  has  disappeared. 

In  the  hands  of  the  few  specialists  of  this  country  who  still  perform  it, 
it  is  claimed  to  be  an  alternative  to  cicsarean  section  in  the  second  stage  of 
labor,  and  to  be  superior  to  that  operation  on  accont  of  its  lower  mortality; 
but  since  the  development  of  the  extraperitoneal  cesarean  section  in  these 
cases,  the  need  for  inibiotomy,  to  escape  the  dangers  of  caesarean  section  in 
patients  either  exhausted  or  presumably  infected,  has  disappeared,  the 
extraperitoneal  cesarean  section  giving  results,  in  the  hands  of  experts 
who  are  trained  in  abdominal  surgery,  that  are  ciuite  equal  to  those  obtained 
by  pubiotomy  in  primary-  mortality,  and  better  results  in  the  patient's 
convalescence  after  the  operation  and  in  her  subsequent  life  history. 


PLATE  CLXIII. 


Doederleins'  needle  passed  behind  the  pubic  bone  and  emergmg  through  the  skm  to  the  outer  side  of  the  labium. 


PLATE  CLXIV. 


The  Gigli  saw  adjusted. 


AFTER-TREATMENT  OF  ABDOMINAL  SECTION  251 

THE  AFTER-TREATMENT  OF  ABDOMINAL  SECTION 

The  routine  followed  in  my  services  is  to  give  the  patient  a  'Murphy 
drip  proctoclysis  of  a  ciuart  of  water  containing  an  ounce  each  of  glucose 
and  bicarbonate  of  soda,  so  timed  as  to  take  an  hour  to  administer.  Manj' 
surgeons  at  present  claim  that  it  is  better  to  give  this  injection  perhaps  in 
smaller  amount  as  an  enema,  on  account  of  the  discomfort  of  the  proctocly- 
sis; but,  if  administered  as  soon  as  the  patient  is  put  to  bed  it  is  finished 
before  complete  recovery  from  ansesthesia,  and  my  patients  make  no  com- 
plaint about  it — in  fact  are  usualh'  unaware  that  it  has  been  given. 

For  the  first  twenty-four  hours  suppositories  of  five  grains  of  asafoetida 
every  three  hours  are  useful  to  control  tympanites.  If  there  is  much 
nausea  the  patient  is  given  a  full  glass  of  water  with  a  teaspoonful  of  bicar- 
bonate of  soda  in  it,  which  is  usually  at  once  rejected,  washing  the  stomach 
out,  whereupon  the  stomach  usually  becomes  retentive.  A  moderate 
Fowler's  position  helps  to  drain  the  stomach  into  the  duodenum,  which 
also  aids  in  the  control  of  nausea.  Water  is  given  in  sips  as  soon  as  the 
patient  can  retain  it.  At  the  end  of  the  first  twenty-four  hours  the  patient 
receives  an  enema  of  six  ounces  milk  of  asafoetida,  six  ounces  water,  one 
drachm  of  turpentine  and  one  drachm  of  Hoffmann's  anodyne;  this  is  to 
expel  the  gas  from  the  intestines.  A  rectal  tube  is  inserted  occasionally 
to  facilitate  the  expulsion  of  gas.  During  the  second  twenty-four  hours, 
albumen  water,  l)arley  water,  clear  broth,  and  whey  are  administered  as 
food,  at  three-hour  intervals  in  four-ounce  quantities.  At  the  end  of  the 
second  twenty-four  hours,  a  course  of  calomel  is  given:  one-fourth  grain 
every  hour  for  eight  doses,  followed  by  two  ounces  of  citrate  of  magnesia 
every  two  hours  for  three  doses;  or,  if  the  patient  objects  to  the  taste  of  the 
citrate,  a  solution  of  Rochelle  salt  is  substituted.  The  administration  of 
the  calomel  makes  the  patient  uncomfortable  for  the  time  being,  but  she 
is  so  much  better  for  it  the  folliiwing  day  that  I  still  continue  it.  Several 
substitutes  have  been  tried  from  time  to  time,  but  they  have  not  been  found 
so  satisfactory.  After  the  bowels  have  been  moved,  the  patient  is  put  on  a 
soft  diet.  The  exaggeration  of  the  distention  and  of  the  nausea  following 
sections  must  occasionally  l^e  combated. 

Of  all  the  abdominal  operations  in  gynaecology,  the  classical  csesarean 
section  is  most  apt  to  be  followed  by  tJ^npanites.  Therefore,  eserine 
salicylate  and  strychnia  are  given  hypodennically  directly  after  the  opera- 
tion at  four-hour  intervals,  one-sixtieth  and  one-twentieth  grain  respec- 
tively. Should  excessive  tympanites  develop  after  any  section,  these  rem- 
edies are  employed,  with  a  single  hypodermic  injection  of  an  ampoule  of 
surgical  pituitrin. 

If  the  medicinal  treatment  alone  is  not  sufficient,  the  following  enemata 
in  succession  are  given  at  three-hour  mtervals :   an  ounce  of  alum  in  a  pint 

17 


SS-J  ATLAS  OF  OPERATIVE  GYN/ECOLOGY 

of  water;  the  enema  of  milk  of  asafoetida,  etc.,  already  described;  an  ounce 
of  glycerine,  half  an  ounce  of  turpentine,  half  an  ounce  of  Epsom  salt, 
two  ounces  of  water;  two  and  one-half  drachms  bisulphate  of  quinine,  and 
a  quart  of  water.  A  spice  poultice  is  put  over  the  upper  abdomen,  and  in 
extreme  cases,  after  injecting  the  rectum  with  salt  solution,  an  anal  elec- 
trode is  inserted;  a  sponge  pad  electrode  is  laid  on  the  abdomen  and  as 
strong  a  galvanic  current  as  the  patient  can  stand  (20-40  milliamperes) 
is  turned  on.  The  abdomen  and  rectum  are  then  shocked  by  a  rapid  alter- 
nation of  the  poles,  by  suddenly  switching  the  indicator  on  the  .switch  board 
from  negative  to  positive.  In  this  manner  it  is  possible  to  relieve  tym- 
panites that  would  appear  to  demand  re-opening  the  abdomen  for  an  appar- 
ent obstniction. 

While  the  enemata  are  being  used  it  is  a  useful  adjuvant  if  the  stomach 
will  retain  it  to  administer  two  drachms  of  a  fifty  per  cent,  emulsion  of 
castor  oil  at  hourly  intervals  for  eight  doses.  On  the  failure  of  all  these 
measures,  re-opening  the  abdomen  may  be  called  for,  to  relieve  an  actual 
obstruction. 

Occasionally  an  explanation  for  persistent  and  extreme  tympanites  is 
found  in  a  thrombosis  of  the  mesenteric  veins — usually  a  fatal  complication, 
but  in  one  instance  I  witnessed  recovery  in  a  typical  case. 

As  is  well  known,  nothing  relieves  excessive  vomiting  so  well  as  gastric 
lavage.  A  spice  poultice  over  the  abdomen,  the  Fowler  jiosition  and  cocaine 
internally  in  full  doses,  are  aids;  but  if  the  vomiting  is  due  to  infection, 
acute  dilatation  of  the  stomach,  or  obstruction,  no  treatment  directed  to 
the  stomach  alone  will  be  of  any  use. 

//;  the  after-treatment  of  plastic  operations  the  dusting  of  the  external 
wound  with  formic  bisnuith  iodide,  avoidance  of  douches  till  after  the  first 
week,  and  if  possible  spontaneous  urination  are  the  main  principles  to  be 
observed.  In  secondary  hemorrhages,  washing  out  the  vagina  with  hot 
water,  putting  the  patient  on  an  operating  table  and  packing  the  vagina 
by  the  aid  of  a  very  narrow  Sims  speculum,  firmly  but  not  too  forcibly 
controls  the  bleeding  without  tearing  the  vaginal  wounds  open. 

The  differential  diagnosis  of  internal  bleeding  and  shock  after  an  ab- 
dominal operation  was  at  one  time  an  anxious  matter;  but,  with  the  improved 
technic  of  abdominal  surgery,  secondary  hemorrhage  into  the  abdominal 
cavity  after  the  wound  is  closed  is  so  rare  that  it  scarcely  ever  has  to  be 
considered.  In  my  two  hospital  services  there  has  been  but  one  intra- 
peritoneal hemorrhage  during  recovery  from  an  abdominal  operation  in 
the  course  of  many  years.  If  the  question  must  be  considered,  Polak's 
observations  would  have  great  walue.  The  low  pulse  pressure  and  the  leuco- 
cytosis  of  hemorrhage  are  the  main  distinguishing  features.  For  shock,  a 
good  routine  treatment  is  artificial  heat  by  the  electric  canopy;  enemata 


AFTER-TREATMENT  OF  ABDOMINAL  SECTION  253 

every  four  hours  of  one  ounce  predigested  beef;  twenty  grains  carbonate  of 
ammonia,  one-half  ounce  whiskey,  and  four  ounces  water;  alternating  with 
the  enemata,  hypodermics  of  a  digitalis  preparation  and  strychnia. 

For  the  acute  anaemia  following  an  operation  which  has  been  preceded 
or  accompanied  by  severe  hemorrhage,  intravenous  salt  solution  injections 
are  first  tried  during  or  immediately  after  the  operation.  There  is  almost 
always  a  response.  But  if  there  is  not,  or  if  some  hours  later  the  patient's 
pulse  fails  again,  actual  transfusion  by  the  citrate  of  sodium  method, 
five  hundred  to  seven  hundred  cubic  centimeters,  is  employed.  For  this 
purpose  a  donor  is  kept  in  readiness  and  the  tests  for  haemolysis  are  made, 
in  a  case  of  need. 

SURGERY  OF  THE  MAMMARY  GLAND 

It  is  unusual  to  devote  to  the  breast  a  section  of  a  book  on  the  operative 
treatment  of  the  diseases  of  women;  but  there  is  no  class  of  physicians  who 
see  a  larger  number  of  pathological  conditions  of  all  kinds  in  the  breast 
than  those  who  are  especially  interested  in  diseases  peculiar  to  women. 

In  the  practice  of  such  a  specialist  there  is  a  constant  necessity  for  the 
diagnosis  and  recommendation  for  treatment  of  various  pathological  con- 
ditions in  the  female  breast — from  the  minor  inflammatory  and  congestive 
conditions  to  the  most  serious  pathological  new  formations.  It  would 
appear,  therefore,  that  it  is  desirable,  for  any  special  worker  in  conditions 
peculiar  to  women,  to  familiarize  himself  with  all  the  pathological  conditions 
in  the  breast,  and  to  cultivate  skill  in  their  necessary  operative  treatment. 

Surgery  of  the  breast  is  not  difficult  to  anyone  who  specializes  in  pelvic 
and  abdominal  surgery.  There  is  no  reason,  therefore,  why  the  g>Tia?cologist 
should  not  include  operative  treatment  for  conditions  of  the  breast  in  his 
special  work.  It  appears  to  the  author  an  advantage  to  patients  if  this  is 
done.  The  patient  is  more  likely  to  consult  someone  known  to  be  interested 
in  female  diseases,  if  she  develops  an  abnormaUty  in  the  breast,  than  she 
is  to  consult  any  other  kind  of  specialist:  and  there  is  always  a  necessity  for 
differentiating  the  minor  conditions,  incitlental  to  functional  activity  in 
the  child-bearing  process,  from  more  serious  conditions.  Anyone  in  control 
of  a  large  service  in  obstetrics  and  gj'nsecology  has  a  better  opportunity 
to  familiarize  himself  with  the  diagnosis  and  treatment  of  all  breast  condi- 
tions than  the  general  surgeon.  For  all  these  reasons,  therefore,  it  would 
seem  that,  in  the  future,  the  pathology  and  treatment  of  the  mammarj^  gland 
should  be  a  part  of  every  gyngecologist's  work. 

Surgical  Treatment  of  ^^Iammary  Abscess. — The  author  has  for  a 
number  of  years  adopted  the  following  plan  of  treatment,  after  experience 
with  others  that  were  not  so  satisfactory : 


254  ATLAS  OF  OPERATIVE  GYN.E(  OLOGY 

The  area  of  suppuration  is  first  carefully  mapped  out;  then  a  small 
incision  is  made  in  the  most  dependent  point  of  the  suppurative  area,  or 
a  trifle  below  it,  as  the  woman  lies  on  her  back.  At  this  point  a  small  incision 
through  the  skin  and  sujiraficial  fascia  is  made;  through  this  a  long  Pean 
forceps  is  inserted  and  plunged  through  the  deeper  portion  of  the  sup]:)urative 
area  until  the  point  of  the  instiimient  makes  a  projection  under  the  skin, 
opposite  to  the  point  where  the  first  incision  is  made.  A  small  incision  is 
now  made  upon  the  projecting  point  of  the  instrument,  which  is  inished 
further  through  until  it  appears  plainly  in  view.  A  rubl)er  drainage  tube 
with  only  one  fenestra  in  the  middle  of  it  is  seized  by  the  forceps  and  pulled 
back  until  it  appears  through  the  original  incision. 

The  drainage  tube  traverses  the  whole  extent  of  the  infected  area. 
At  a  point  midway  between  the  first  two  incisions  and  in  the  lowest  margin 
toward  the  pectoral  surface,  another  incision  is  made,  through  which  a  Pean 
forceps  is  forced  until  it  appears  at  a  point  opposite,  traversing  the  whole 
extent  of  the  involved  breast.  A  drainage  tube  is  pulled  through  as  before, 
with  one  fenestra  in  it,  in  the  middle. 

In  a  case  of  extensive  suppuration  two  or  three  more  tubes  may  be 
required,  until  it  is  obvious  that  every  suppurative  area  is  tapped  and  well 
counter-drained. 

Safety  pins  are  then  inserted  through  the  projecting  ends  of  the  drainage 
tube  and  they  are  cut  ofT  above  the  safety  pins  so  as  not  to  leave  too  much 
tube  projecting  to  be  pressed  upon  by  the  dressing.  By  a  device  invented 
by  Dr.  Edmund  B.  Piper,  while  in  the  American  Ambulance  Service  in  Paris, 
fluid  may  be  injected  into  both  ends  of  the  drainage  tube  and  is  consequently 
forced  out  through  the  single  fenestra  in  the  middle,  in  this  way  flushing  the 
abscess  cavity  and  the  drainage  tract  efficiently;  whereas,  by  the  older  plan 
of  injecting  fluids  into  the  drainage  tube,  the  inner  surface  of  the  tube  was 
kept  clean  without  much  influence  on  the  drainage  tract  or  the  abscess 
cavity  (Fig.  25). 

As  an  irrigating  fluid  Dakin's  fluid  may  be  employed ;  but  I  have  found 
it  better  to  use  this  only  occasionally,  employing  in  the  interval  a  mild 
antiseptic  solution,  like  one  to  six  thousand,  permanganate  of  potash  or  a 
boracic  acid  solution,  the  breast  being  irrigated  every  three  hours,  but  only 
once  or  twice  a  day  by  the  Dakin  fluid.  The  advantages  of  this  plan  of 
dealing  with  a  mammary  abscess  are  that  there  is  the  minimum  of  disfigure- 
ment of  the  breast ;  the  least  possible  sacrifice  of  secreting  glandular  material ; 
the  earliest  possible  cure  of  the  abscess,  with  the  least  amount  of  suffering 
to  the  patient. 

The  alternative  plan  of  making  a  large  incision,  or  of  making  an  incision 
sufficiently  great  to  insert  the  finger,  does  not  so  surely  .secure  these  results. 
The  large  incision  through  the  whole  extent  of  the  suppurative  area  makes  a 


SURGERY  OF  THE  MAMMARY  GLAND 


255 


regrettable  disfigurement  of  the  breast, and  sacrifices  an  unnecessary  amount 
of  gland;  it  also  entails  on  the  woman  a  greater  risk  of  lacteal  fistula.  The 
other  plan  of  using  the  finger  to  break  up  septa  between  suppurating  areas 


Fia. 


-Piper's  niethod  of  irrigating  infected   sinuses  and  drainage  tracts;  devised  by  Majnr  E.  B.  Piper,  of  the 
American  Ambulance  Service  in  Paris  and  subsequently  adopted  by  Dakin  and  Carrel. 


can  never  be  depended  on;  it  is  often  impossible  to  reach  with  the  finger  so 
deep  or  so  far  as  may  be  required,  and  by  using  the  digital  method  unneces- 
sary trauma  and  destruction  of  tissue  sometimes  ensue. 

Between  the  irrigations  the  breast  is  covered  with  an  ample  cjuantity 
of  absorbent  gauze,  which  is  kept  in  place  by  an  ordinary  Murphy  breast 
binder;  the  corresponding  arm  being  .supported  in  a  sling. 


256  ATLAS  OF  OPERATIVE  GYNAECOLOGY 

As  soon  as  the  systemic  symptoms  subside — that  is,  as  soon  as  the 
temperatui'e  becomes  normal — the  patient  is  allowed  out  of  bed  and  is 
given  the  maximum  of  good  air  and  bright  sunlight,  with  a  generous  support- 
ing diet  and  mild  stimulant  in  the  shape  of  a  moderate  qauntity  of  red  wine 
with  the  principal  meal.  It  is  possible  to  continue  mu'sing  with  the  vmaf- 
fected  breast;  but  as  a  rule  it  is  better  not  to  do  so,  as  the  stimulus  of  lacta- 
tion continues  the  congestion  and  engorgement  of  the  infected  breast. 

The  average  length  of  time  required  for  convalescence  is  about  two 
weeks;  the  drainage  tubes  are  usually  removed  within  ten  days,  a  small 
strip  of  gauze  being  inserted  in  the  drainage  opening  for  two  or  three  days 
afterward.  These  are  then  removed;  small  squares  of  surgeon's  lint  with 
zinc  ointment  are  put  over  the  raw  surface  of  the  exit  orifices  of  the  drainage 
tracts,  and  the  breast  is  then  subjected  to  compression  by  layers  of  rubber 
adhesive  plaster  put  on  in  squares  from  the  base  of  the  breast  toward  the 
nipple.  An  application  occasionally  of  weak  nitrate  of  silver  solution  to 
the  granulating  area,  around  the  openings  of  the  drainage  tracts,  hastens 
their  cicatrization  and  the  restoration  of  skin  over  them. 

If  the  suppurative  area  is  quite  limited  and  superficial,  a  single  small 
incision  into  it,  with  the  application  afterward  of  a  Bier  cup  may  suffice, 
or  it  may  be  necessary  to  insert  only  a  single  drainage  tube  for  a  compara- 
tively short  time.  If  the  abscess  is  under  the  breast — the  so-called  post- 
mammary  abscess,  between  the  breast  and  the  pectoral  fascia,  lifting  the 
breast  from  the  chest  and  giving  a  peculiar  elastic  sensation  to  the  whole 
breast  when  palpated — the  drainage  should  be  conducted  as  described  in 
the  treatment  of  an  ordinary  extensive  mamary  abscess,  except  that  the 
incisions  and  the  drainage  tubes  are  between  the  breast  proper  and  the 
pectoral  surface. 

In  the  course  of  some  twenty-five  or  thirty  years'  experience  with 
mammary  abscesses  it  has  been  twice  necessary  to  amputate  the  breast 
for  a  mammary  abscess  which  had  been  long  neglected  before  proper  treat- 
ment was  api)lied,  and  in  which  it  was  impossible  to  secure  a  cessation  of 
suppurative  discharge  and  a  healing  of  the  drainage  sinuses.  In  such  cases, 
some  unusual  infection  must  be  suspected — not  the  ordinary  staphylococcic 
or  streptococcic  infection,  but  tuberculosis,  syphilis,  or  an  infection  by 
some  of  the  fungi.  In  rare  instances,  and  in  long  neglected  cases,  the  suppu- 
ration may  extend  quite  far  beyond  the  breast  itself,  into  the  axilla  or  even 
on  to  the  upper  and  posterior  aspects  of  the  shoulder.  The  systemic  symp- 
toms in  such  cases  are  severe,  and  it  may  be  necessary  to  resort  to  vaccine 
and  serum  treatment  in  addition  to  the  surgical  inter\'ention. 

In  young  infants  the  pus  may  burrow  through  the  thoracic  walls  into 
the  pleura,  but  personally  I  have  never  seen  this  in  an  adult.  It  might, 
however,  occur  in  a  long  neglected  and  extremely  severe  infection. 


SURGERY  OF  THE  MAMMARY  GLAND  257 

The  sooner  mammary  abscesses  are  opened  the  better.  It  is  not  wise 
to  wait  for  the  classical  symptoms  of  suppuration  elsewhere,  if  the  symptoms 
of  mastitis  continue  unabated  for  three  or  four  days ;  if  there  is  persistent 
fever,  leucocytosis,  redness  of  the  skin  or  a  dusky  red  hue,  and  some 
oedema,  an  incision  or  incisions  are  always  required.  It  is  often  possible  to 
abort  suppuration  by  an  early  incision  into  an  inflammed  area  before  actual 
pus  formation  has  occurred.  Inefficient  and  too  long  postponed  surgical 
treatment  result  in  almost  indefinite  inflammation  and  suppuration.  I 
have  .seen  cases  of  puerperal  insanity  develop  in  the  course  of  a  mammary 
abscess  which  had  lasted  for  more  than  six  weeks,  with  one  or  two  insufficient 
incisions  and  inadecjuate  drainage.  Ill-success  in  the  treatment  of  mammary 
abscess  often  brings  unnecessary  discredit  to  the  general  physician,  with 
loss  of  reputation  and  practice. 

If  speedy  success,  therefore,  does  not  follow  treatment,  it  is  good  policy 
to  refer  such  cases,  without  unnecessary  delay,  to  a  specialist,  who  can 
usuallj'  secure  a  good  result  in  a  moderate  length  of  time  or  who  can,  at 
any  rate,  better  bear  the  responsibility  of  a  long  continued  and  delayed 
convalescence.  If  this  is  not  done,  it  is  often  a  difficult  task  for  the  con- 
sultant to  reconcile  the  family  and  the  original  medical  attendant. 

In  addition  to  the  operative  treatment  for  mammary  abscess,  the 
following  operations  are  required  for  pathological  conditions  of  the  breast: 

(1)  Excision  of  Cystic  or  Solid  Tumors  by  an  Incision  Directly  over 
the  Growths  and  Their  Enucleation.  Removal  of  Supernumerary  Glands. 
Removal  of  Sm-face  Growths  (Papillomata). 

(2)  Excision  of  a  Growth  or  Portion  of  the  Breast  Tissue  by  the 
Thomas-Warren  Incision  which  is  Invisible  Afterward  in  the  Erect  Posture. 
Plastic  Resection. 

(3)  Amputation  of  the  Breast  for  Non-MaUgnant  Conditions  which 
do  not  Necessitate  the  Dissection  of  the  Axilla  and  the  Removal  of  the 
Subjacent  Tissues,  as  the  Pectoral  Muscles  and  Fascia. 

(4)  Subcutaneous  Amputation  of  the  Breast  with  Preservation  of  the 
Nipple. 

(5)  Amputation  of  the  Breast  for  Malignant  Disease  Including  a  Dis- 
section of  the  Axilla;  Removal  of  Glands  and  Fatty  Tissue  and  Removal  of 
Pectoral  Muscles  and  Fascia. 

(6)  Plastic  Operations  on  the  Breast:  A,  for  Inverted  Nipple  (UmbiU- 
cation  of  Nipple) ;  B,  for  Hypertrophy ;  C,  for  Pendulous  Breast — Mastopexy. 

(1)  Excision  of  Cystic  or  Solid  Tumors  by  .\n  Incision  Directly 
Over  the  Growths  and  Their  Enucleation.  Removal  of  Super- 
numerary' Glands.  Removal  of  Surf.\ce  Growths  (Papillom.\ta) 
(Fig.  26). — If  no  attention  need  be  paid  to  the  disfigurement  of  a  scar  on  the 
breast,  it  is  always  more  convenient  to  make  an  incision  directly  over  non- 


-i5H  ATLAS  OF  OPERATn  E  (iVX.KCOLOCiY 

malignant  fjrowths  and  to  effect  their  removal  either  by  enucleation  or 
excision.  This  is  almost  alwaj's  done  in  the  removal  of  sniiernunierary 
glands,  which  may  cause  much  annoyance  to  the  patient  by  their  situation 
or  by  their  discharge  of  secretions,  or  may  be  subject  to  such  irritation  that 
there  is  danger  of  the  development  in  them  of  malignant  conditions. 

If  the  patient  belongs  to  a  class  of  life  in  which  distiguronient  wouUl 
be  a  great  disadvantage,  every  effort  must  be  made  to  a\()id  it,  by  the 
Thomas-Warren  incision  to  be  subse(iuentl3'  described.  The  most  inijiortant 
point  to  decide,  before  attemjiting  the  excision  or  enucleation  of  a  cystic 
or  solid  tumor  in  the  breast,  is  its  possible  malignancy.  Contraction  of  the 
nipple,  adhesion  of  the  skin,  the  peculiar  pig-skin  appearance,  extreme 
hardness  of  a  malignant  growth,  idceration  of  the  skin,  the  age  of  the  jiatient 
— all  have  to  be  considered;  l)ut  there  will  always  be  a  ]iossil)ility  of  doul^t. 
It  is  therefore  advantageous,  to  a  greater  degree  in  tliis  than  perhaps  in 
any  other  branch  of  surgery,  to  have  prepared  a  rai)id  freezing  microtome 
and  a  microscope,  so  that  a  competent  pathologist  can  make  an  inuuediate 
diagnosis  as  to  the  true  nature  of  the  tumor. 

With  the  possibility  of  malignancy  in  mind,  any  direct  incision  into  the 
tumor  should  be  carefully  avoided;  and  it  is  often  a  distinct  ad\antage  to 
excise  a  portion  of  the  breast  tissue  a  little  wide  of  the  tumor,  to  be  removed 
with  it  without  coming  in  direct  contact  with  the  growth  itself.  Moreover 
it  is  impossible  to  enucleate  some  growths,  and  the  excision  of  surrovnuling 
tissue  is  a  necessity. 

The  possibility  of  a  lacteal  fistula  must  also  be  borne  in  mind;  so  that 
the  incisions  in  the  breast,  to  gain  access  to  the  tumor  and  to  effect  its 
removal,  should  always  be  made  parallel  with  the  milk  ducts.  A  disadvan- 
tage of  the  direct  incision  is  that  it  maj'  not  permit  a  sufficiently  wide  explo- 
ration of  the  breast,  so  that  most  operators  (including  the  author)  prefer  the 
Thomas-Warren  incision — which  avoids  disfigurement,  permits  the  removal 
of  a  tumor  from  any  portion  of  the  manmiary  gland  and  also  enables  the 
operator  to  conduct  as  wide  an  exploration  of  the  l)reast  as  he  desires. 

In  closing  the  wound  after  direct  incision  over  a  mammary  growth, 
care  must  be  taken  to  obliterate  by  tier  sutures  of  catgut  the  cavity  left 
behind;  otherwise  the  skin  over  the  cavity  will  show  a  depression  more 
disfiguring  than  the  wound  in  the  breast,  and  moreover  there  is  a  likeli- 
hood of  haematoma  formation,  infection  of  the  wound,  and  a  comjjlication 
by  a  mammary  abscess  after  what  should  be  a  trifling  operation  with  an 
immediate  recovery. 

It  .should  be  a  rule  of  practice  to  remove  all  tumors  in  the  breast. 
Malignant  degeneration  is  always  possible.  The  nature  of  the  tumor  can 
never  be  certainly  determined  without  microscopic  examination;  future 
growth  demanding  amputation  of  the  breast  is  not  unlikely,  and  as  the 


Fig.   26. — PapiUunia  of  breast. 


260  ATLAS  OF  OPERATIVE  GYNECOLOGY 

operation  is  a  simple  and  easy  one,  usually  possible  under  local  anesthesia, 
there  can  be  no  objection  to  it  unless  the  patient  is  the  subject  of  some 
grave  systemic  disease.  If  operation  is  declined  the  patient  should  be 
urged  to  report  at  frequent  intervals  for  examination. 

(2)  Excision  of  a  Growth  or  Portion  of  the  Breast  Tissue 
AND  Exploration  of  the  Mammary  Gland  by  the  Thomas-Warren 
Incision  which  is  Invisible  Afterward  in  the  Erect  Posture.  Plastic 
Resection. — There  are  many  conditions  in  the  mammary  gland  requiring 
surgical  treatment  which  can  be  dealt  with  by  an  operation  leaving  no 
disfigurement,  obviously  an  important  consideration  with  many  women. 
Tumors  of  moderate  size  can  thus  be  removed,  the  breast  can  be  explored 
for  possible  malignant  growths,  portions  of  it  may  be  excised  for  conditions 
such  as  imperfect  involution  and  cystic  formation;  or  areas  of  the  breast 
can  be  reached  and  drained  in  this  manner,  better  than  by  direct  incision 
in  certain  cases.  The  o])eration  is  not  applicable  to  tumors  in  a  situation 
most  difficult  to  reach  by  an  incision  under  the  breast  and  to  its  outer  side. 
As  Deaver  points  out,  growths  on  the  inner,  upper  quadrant  of  the  breast 
are  usually  more  conveniently  reached  by  the  direct  incision  over  them. 
But  even  in  this  situation  it  is  possible  to  deal  with  the  conditions  by  the 
Thomas-Warren  incision,  if  there  is  a  cogent  reason  for  avoiding  the  slightest 
disfigurement.  Many  women  will  consent  to  this  operation  who  might 
decline  operative  treatment  which  would  leave  a  visible  scar  in  evening 
dress;  but  if  this  consideration  need  not  be  taken  into  account,  in  women  of 
a  class  who  need  not  concern  themselves  about  evening  dress,  or  in  women 
approaching  middle  age  and  the  termination  of  the  child-bearing  period, 
an  amputation  of  the  breast  in  extensive  invohement,  or  for  removal  of  a 
tumor  of  considerable  size,  may  be  better  than  plastic  resection  or  the 
removal  of  the  growth  by  direct  incision  over  it. 

The  Thomas- Warren  operation  is  usually  referred  to  as  plastic  resection 
of  the  breast,  and  is  here  described  by  its  author  as  first  performed,  with 
later  modifications  by  the  operator: 

"The  patient  standing  erect  and  the  mamma  being  completely  exposed, 
a  semicircular  line  is  drawn  with  pen  and  ink  exactly  in  the  fold  which  is 
created  by  the  fall  of  the  organ  upon  the  thorax.  This  line  encircles  the 
lower  half  of  the  breast  at  its  juncture  with  the  trunk.  As  soon  as  it  has 
dried  the  patient  is  anaesthetized,  and  with  the  bistoury  the  skin  and  areolar 
tissue  are  cut  through,  the  knife  exactly  following  the  ink  line  just  men- 
tioned until  the  thoracic  muscles  are  reached  (Fig.  27).  From  these  the 
mamma  is  now  dissected  away  until  the  line  of  dissection  represents  the 
chord  of  an  arc  extending  from  extremity  to  extremity  of  the  semicircular 
incision.  The  lower  half  of  the  mamma  which  is  now  dissected  off  is,  after 
ligation  of  all  bleeding  points,  turned  upward  by  an  assistant  and  laid  upon 
the  chest  wall  just  below  the  clavicle. 


SURGERY  OF  THE  MAMMARY  GLAND 


261 


"An  incision  is  then  made  upon  the  tumor  from  imdemeath  bj'  the 
bistoury,  a  pair  of  short  \'olselhuii  forcei)s  is  firmly  fixed  into  it,  and,  while 
traction  is  made  by  these,  its  connections  are  snipped  by  scissors — the  body 
of  the  tumor  being  closely  adhered  to  in  this  process — and  the  growth  is 
removed.  All  hemorrhage  is  then  checked  and  the  breast  is  put  back  into 
its  original  position. 

"Its  outer  or  cutaneous  surface  is  entirely  uninjured,  and  the  only 
alteration  which  has  been  effected  in  the  organ  is  the  leaving  of  a  cavity 
which  was  formerly  occupied  by  the  tumor.    A  glass  tube  with  small  holes 


I'lu    27  — Priiiia]>  iiiL-isioii  f(M' the  TliMiiKis-Wuneii  uperatioli  (.Denvciuiid    McFarlando       1  ).>.   l;nast";    courtesy 

P.  Blakiston's  Son  &  Co.) 

at  its  upper  extremity  and  along  its  sides,  about  three  inches  in  lengtli,  and 
of  about  the  size  of  a  number  10  urethral  sound,  is  then  passed  into  the 
cavity  between  the  lips  of  the  incision,  and  its  lower  extremity  is  fixed  to  the 
thoracic  walls  by  adhesive  plaster.  The  incision  is  closed  with  silk  and 
covered  with  collodion.    The  tube  is  removed  in  nine  days." 

The  operation  is  designed  to  take  the  place  of  those  exploratory  incisions 
which  are  often  inadequate  for  the  purpose,  or  are  so  situatetl  as  to  leave  a 
cicatrix  in  a  part  of  the  integument  frequently  exposed  to  view.  It  is  also 
so  planned  as  to  expose  freely  every  part  of  ihe  gland,  and,  therefore,  to 
accomplish  all  that  an  amputation  would  do  in  doubtful  cases.  An  opera- 
tion that  can  relieve  the  mind  of  the  patient  from  all  uncertainty  as  to  diag- 


iGi 


ATLAS  OF  OPERATIVE  GYNAECOLOGY 


nosis,  produces  no  subsequent  deformity,  and  entails  but  little  discomfort 
and  sacrifice  of  time,  seems  well  indicated  as  a  substitute  for  the  various 
forms  of  treatment  which  have  from  time  to  time  been  suggested — such 
as  puncture,  aspiration,  or  small  exploratory  incisions.  It  is  also  well 
adapted  to  overcome  the  fears  of  those  who  shrink  from  any  operative 
interference  whatever. 

In  early  operations  I  began  with  an  incision  similar  to  that  described 
by  Thomas,  but  have  changed  it  to  coincide  with  the  edge  of  the  outer 
hemisphere;  as  this  incision  gives  a  freer  access  to  the  upper  hemisphere. 


Flo.  28. — Conservalive  amputation  of  breast.  Primary 
skin  incision.  (Deaver  and  McKarland's  "The  Breast"; 
Courtesy  P.  Blakistou's  Son  &  Co.) 


Fk;.  29. — Conservative  amputation  of  the  breast,  tikin 
flaps  reflected.  (  Deaver  and  McFarland's  "The  Breast"; 
P.  Blakiston's  Son  &  Co.  ) 


and  at  the  same  time  to  the  outer  hemisphere  of  the  gland — regions  more 
frequently  the  seat  of  tumors  than  the  inner  quadrants. 

By  prolonging  the  incision  slightly  along  the  anterior  axillary  border, 
the  breast  can  be  thrown  over  toward  the  sternum,  and  the  most  remote 
regions  of  the  gland  freely  exposed.  As  the  breast  falls  not  only  downwards 
but  outward,  when  the  patient  is  in  the  upright  position,  this  incision  is 
concealed  from  view  (Fig.  27). 

The  dissection  should  be  carried  down  to  the  outer  edge  of  the  pectoralis 
major  muscle;  when  fibers  of  this  muscle  have  been  exposed,  the  knife  will 
have  passed  through  the  deep  layer  of  the  superficial  pectoral  fascia,  a 
fascia  which  covers  the  posterior  surface  of  the  gland.  This  layer  is  sepa- 
rated from  the  deep  pectoral  fascia  covering  the  pectoralis  major  muscle  by 
a  loose  layer  of  connective  tissue.    The  loose  connective  tissue  enables  the 


SURGERY  OF  THE  MAMMARY  GLAND  263 

dissection  to  be  carried  easily  between  the  gland  and  the  muscle,  so  that 
they  are  quickly  separated  from  each  other.  The  left  hand  of  the  operator 
can  now  manipulate  the  breast  so  as  to  expose  the  entire  posterior  surface 
of  the  gland.  The  gland  tissue  is  covered  by  the  posterior  layer  of  the 
pectoral  fascia,  but  is  readily  recognized  beneath  it,  as  are  also  any  cysts 
or  tumors  that  may  be  present. 

An  incision  radiating  from  the  center  to  the  periphery  of  the  gland  should 
be  made  through  the  fascia,  to  expose  the  subjacent  growth.  The  segment 
of  the  gland  containing  the  tumor  should  now  be  removed  by  two  radiating 
incisions  which,  meeting  at  the  center  of  the  gland,  include  a  V-shaped 
portion  of  its  tissue. 

The  knife  should  make  a  clean  cut  through  the  gland  tissue  down  to  the 
loose  adipose  tissue  which  lies  in  front  of  the  gland.  This  adipose  layer 
should  not  be  removed,  as  its  presence  is  important  in  preventing  a  subse- 
quent depression  at  this  point.  No  attempt  should  be  made  to  dissect  out 
the  tumor,  whether  it  be  solid  or  cystic.  Solid  tumors,  such  as  the  peri- 
ductal fibroma,  or  a  cystadenoma,  are  so  intimately  associated  with  the 
gland  tissue  that  they  cannot  be  "shelled."  The  fibers  of  the  capsule 
seem  to  be  continuous  with  those  of  the  stroma  of  the  gland.  Any  attempt, 
therefore,  at  a  dissection  of  the  tumor  is  followed  by  a  considerable  lacera- 
tion of  the  surrounding  tissues.  It  is  desirable  to  avoid  cutting  into  cyst 
cavities,  one  or  two  of  which  are  usually  found  in  the  same  quadrant. 

In  the  case  of  a  single  solid  tumor,  the  V-shaped  wound  should  be  care- 
fully approximated  with  a  double  row  of  sutures,  one  adjusting  the  anterior 
edges  of  the  wound  and  the  other  its  posterior  lips.  The  full  thickness  of 
the  gland  at  each  side  will  thus  be  brought  into  contact,  and  no  gap  left 
to  cause  a  depression  on  the  surface  of  the  breast. 

In  the  case  of  the  presence  of  cysts  (in  abnormal  involution  of  the 
breast)  a  further  exploration  of  the  gland  tissue  is  necessary,  for  although 
the  group  of  larger  cysts  forming  the  tumor,  for  which  the  operation  has 
been  performed,  are  usually  clustered  together  in  one  quadrant,  there  are 
also  numerous  minute  cysts  in  other  parts  of  the  gland  which  have  escaped 
detection.  If  these  are  left  undisturbed,  they  may  grow  later  and  involve  a 
second  operation. 

After  the  removal  of  the  cluster  of  large  cysts  by  the  V-incision,  the 
remaining  segments  of  the  gland  can  be  explored  by  a  series  of  radiating 
incisions.  In  this  way  all  the  smaller  cysts  are  laid  open,  a  procedure  which 
is  sufficient  to  insure  their  permanent  disappearance.  Cysts  the  size  of  a 
pea  can  be  snipped  out  with  scissors.  Smaller  cysts  can  be  left  after  being 
laid  open.  The  number  of  these  radiating  incisions  may  vary  from  three  or 
or  four  to  double  that  number.  It  depends  largely  upon  the  amount  of 
gland  tissue  present.    Many  breasts  consist  of  but  little  else  than  adipose 


264  ATLAS  OF  OPERATIVE  GYN^XOLOGY 

tissue  interspersed  with  bands  of  connective  tissue.  Usually  two  or  three 
such  incisions  are  sufficient  to  satisfy  one  that  the  gland  has  been 
thoroughly  explored. 

In  case  an  operation  has  been  jierfornied  for  the  purpose  of  settling  a 
doubtful  diagnosis  of  malignant  disease,  the  breast  may  be  sliced  as  freely 
as  a  brain  is  at  autopsy,  provided  the  radiating  method  is  adopted,  without 
danger  of  interfering  with  its  vitality. 

It  is  usually  unnecessary  to  close  these  incisions  with  sutures,  as  their 
lips  drop  together  naturally  when  the  organ  is  folded  back  on  to  the  pectoral 
muscle.  If,  however,  any  tissue  has  been  dissected  out  from  the  sides  of  one 
of  these  incisions  it  is  well  to  catch  the  edges  together  with  a  single  suture. 
In  some  operations  a  very  large  amount  of  tissue  has  to  be  removed,  as  in 
the  case  of  larger  cysts;  and  then  it  is  difficult,  if  not  impossible,  to  adhere 
to  the  radiating  system  of  cutting.  Keeping,  however,  in  mind  that  nothing 
must  be  removed  excej^t  acinous  tissue,  a  great  deal  of  the  cortical  portion 
of  the  gland  can  be  saved  as  well  as  considerable  portions  of  the  stroma,  and 
all  the  surrounding  adipose  tissue  of  the  breast.  The  somewhat  jumbled 
mass  of  tissue  which  remains  behind  may  be  so  brought  together  by  buried 
sutures,  by  the  quilting  or  purse-string  methods  of  sewing,  that  a  well- 
formed  breast  may  be  built  up  from  what  is  left  behind. 

A  second  V-.shaped  incision  is  occasionally  necessary  for  large  cysts  in 
other  quadrants,  but  I  have  rarely  been  obliged  to  resort  to  it.  All  hemor- 
rhage should  now  be  arrested.  This  can  be  done  partly  by  pressure  and 
partly  by  ligature.  Catgut  is  the  only  material  that  should  be  used  for  this 
purpose,  as  silk  leaves  a  more  or  less  permanent  knot  behind  which  may  act 
as  a  source  of  irritation. 

The  V-shaped  openings  should  next  be  sutured  in  the  way  above  de- 
scribed, and  the  gland  is  now  released  from  the  hand  of  the  operator  and 
dropped  back  on  the  pectoral  muscle.  It  will  be  found  that  the  various 
incised  portions  of  the  gland  resume  their  natural  positions,  and  fit 
accurately  together. 

The  gland  should  next  be  anchored  to  the  outer  edge  of  the  fascia  of 
the  pectoral  muscle.  This  holds  the  gland  firmly  in  its  place.  A  second 
row  of  sutures  should  be  taken  through  the  deep  layer  of  the  superficial 
fascia  before  closing  the  outer  edges  of  the  wound  with  silk-worm  gut. 
This  last  row  of  buried  sutures  is  useful  in  removing  strain  from  the  surface 
sutures.  It  is  not  an  uncommon  occurrence  to  find  a  folding  in  or  inversion 
of  the  nipple,  particularly  in  a  case  of  abnormal  involution.  This  condition 
should  be  distinguished  from  retraction  of  the  nipple,  seen  in  carcinoma. 

This  deformity  can  easily  be  remedied  during  the  operation  by  dissec- 
tion from  Ix^hind,  so  as  to  lay  bare  the  base  of  the  nipple,  where  a  purse- 
string  suture  can  be  applied  in  such  a  way  as  to  force  the  nipple  outward. 


SURGERY  OF  THE  MAMMARY  GLAND  265 

In  cases  of  doubtful  tumor,  where  cancer  is  suspected,  the  disease  can 
be  approached  through  the  incision  made  for  plastic  resection.  It  is  well, 
however,  to  carry  the  incision  so  as  to  separate  the  primary  nodule  from  the 
lymphatic  circulation  by  extending  it  a  little  farther  along  the  axillary 
border.  WTien  the  breast  is  freed  from  the  pectoral  muscle,  all  danger  of 
forcing  cancerous  juices  through  the  lymphatic  channels  is  averted.  If  the 
nodule  proves  to  be  cancer,  the  small  cut  which  has  laid  it  open  should  be 
immediately  closed  by  a  suture,  and  the  major  operation  proceeded  with 
immediately. 

The  dressing  (after  plastic  resection)  should  be  applied  so  as  to  produce 
lateral  compression  of  the  lower  and  upper  hemispheres,  as  the  ordinary 
swathe  tends  toflatten  out  the  gland  and  put  a  strainupon  the  buried  sutures. 
For  this  purpose  I  have  devised  the  "empire"  bandage.  The  material  of 
the  bandage  should  be  of  compress  cloth  or  cheviot  about  five  inches  wide, 
and  long  enough  to  encircle  the  chest  and  cross  diagonally  in  front.  At  the 
point  of  crossing  it  should  be  caught  with  a  safety  pin,  and  pinned  like  a 
diaper.  The  ends  which  cross  each  other  at  right  angles  are  then  folded 
longitudinally  so  as  to  form  a  "box  plait"  and  are  attached  to  suspenders 
crossing  over  the  shoulders. 

(3)  Amputation  of  the  Breast  for  Non-Malignant  Conditions 
which  do  not  necessitate  the  dissection  of  the  axilla  and  the 
Removal  of  Subjacent  Tissues,  as  the  Pectoral  Muscles  and  Fascia. 
— This  operation  is  often  required  for  a  number  of  conditions — tumors  of 
considerable  size  and  of  a  non-malignant  nature,  such  as  fibro-adenomata; 
imperfect  involution  of  the  breast,  with  cystic  formation;  intracystic  papil- 
loma (Fig.  30) ;  tuberculous  sinuses  of  the  breast;  such  extensive  suppuration 
and  inflammation  as  completely  to  destroy  the  breast  as  a  secreting  organ ; 
rarer  forms  of  infection,  such  as  actinomycosis,  Paget's  disease  of  the 
nipple  in  its  precancerous  stage,  etc. 

The  decision  as  to  amputation,  plastic  resection,  or  direct  incision  is 
governed  by  several  considerations — justifiable  doubt  as  to  malignancy, 
the  advancing  age  of  the  patient,  her  social  status,  and  her  feeling  in  regard 
to  multilation.  In  case  of  doubt  as  to  the  selection,  it  is  better,  as  a  rule, 
to  incline  to  amputation. 

The  operation  is  easy,  simple,  and  safe.  An  elliptical  incision  is  made 
through  the  skin,  beginning  on  the  inner  periphery  of  the  gland  and  ending 
at  the  outer  periphery,  having  the  nipple  as  the  mid-point  of  the  skin 
between  the  incisions.  The  incision  is  carried  through  the  skin,  fat,  and 
superficial  fascia,  which  are  then  dissected  back  so  as  to  expose  the  upper 
and  lower  peripheries  of  the  breast  (Figs.  28,29).  The  incision  is  then  carried 
through  the  deep  layer  of  the  superficial  fascia,  when  it  is  easy  to  strip  the 
breast  off  by  pulling  it  loose  from  the  connective  tissue  between  the  deep  layer 


■266 


ATLAS  OF  OPERATIVE  GYNJ^X'OLOGY 


of  the  superficial  fascia  and  the  fascia  over  the  pectoraHs  major  muscle. 
Bleeclinjv  jioiuts  are  tlien  secured;  the  deeper  portion  of  tli(>  tissue  is  brought 
together  with  Intel rupted  sutures  of  catgut  and  the  skin  is  miited  by  what- 
ever form  of  suture  the  surgeon  prefers.    Interrupted  sufm-es  of  silkworm 


Fig.  30. — Intracystic  papilloma  of  breast  removed,  with  surr'>iiinlin^  breast  tissue, 
throvigh  Thomas-Warren  incision. 

gut  at  wide  intervals,  with  catgut  sutures  intervening,  so  as  to  secure  accu- 
rate apposition  of  the  skin  wound,  is  the  method  preferred  by  the  author; 
but  any  other  of  the  skin  sutures  is  applicable  to  the  case,  the  union 
almost  always  being  primary  and  leaving  a  narrow,  non-disfiguring  scar. 

In  the  preparation  for  the  operation  I  am  using  the  same  method 
employed  for  abdominal  section — namely,  cleansing  the  skin  with  a  2 
per  cent,  soap  solution,  wiping  it  off,  using  ether  to  remove  the  sebaceous 
material  and  to  further  dry  the  skin;  and  then  rubbing  the  skin  at  and  in 


SURGERY  OF  THE  MAMMARY  GLAM)  267 

the  neighburhood  of  the  incisions  about  to  be  made  witli  phenoco 
solution.  After  the  operation  the  wound  is  covered  with  a  gauze  dressing 
kept  in  place  by  a  six-inch-wide  gauze  bandage,  put  on  in  the  ordinary 
manner  for  a  breast  bandage.  The  corresponding  arm  is  sujiported  in  a 
sling,  and  the  patient  is  allowed  to  get  out  of  bed  on  the  second  day.  (ieneral 
ansesthesia,  preferably  gas  and  oxygen,  is  desirable  for  tins  operation.  Local 
anaesthesia  would  have  to  be  applied  over  too  extensive  an  area  and  reciuires 
too  nuich  time;  but  there  are  certain  systemic  conditions  of  the  patient 
which  might  make  the  local  anaesthesia  preferable.  In  the  vast  majority 
of  cases,  however,  the  gas  and  oxygen  anaesthesia  will  be  found  itleal.  The 
operation  is  a  brief  one;  and  the  consecjuent  convalescence  of  the  patient, 
with  early  rising  from  bed,  is  facilitated  by  the  avoidance  of  ether  or  chloro- 
form. It  is  most  important,  in  this  operation,  to  make  a  rapid  macroscopic 
and  microscopic  examination  of  the  breast  before  closing  the  wound,  to 
determine  the  possibility  of  malignancy  in  the  condition  for  which  the  oper- 
ation is  perfoi'ined.  In  a  certain  percentage  of  cases  reciuiring  amputation 
of  the  breast,  it  is  necessary  to  extend  the  operation  into  the  axilla  for  the 
removal  of  sympathetically  affected  lymphatic  glands,  not  involved  in 
malignancy  but  enlarged,  hardened,  and  pos.sibly  painful  on  account  of 
lymph-adenitis.  It  is  also  quite  possible  to  find,  in  the  axilla,  growths 
similar  to  those  removed  with  the  breast,  particularly  fibro-adenomata. 

(4)  Subcutaneous  Amputation  of  the  Breast  with  Preservation 
OF  the  Nipple. — This  operation  is  sometimes  indicated  tV)r  such  conditions 
as  extensi\'e  imperfect  involution  and  cystic  formation,  or  for  some  large 
tumors  of  a  non-malignant  variety  in\-()lving  the  greater  jiortion  of  the 
breast  tissue. 

The  operation  is  designed  mainly  to  reconcile  some  people  to  an  ampu- 
tation of  the  breast  without  the  disfigurement  of  the  coincident  removal  of 
the  nijiple,  a  patient  sometimes  consenting  to  this  form  of  operation  who 
otherwise  might  decline  the  ordinary  amputation  of  the  breast. 

The  Thomas-Warren  incision  is  utilized  as  already  described,  except 
that  after  reaching  the  loose  connective  tissue  between  the  deep  layer  of 
the  superficial  fascia  and  the  fascia  covering  the  pectoral  muscle,  there  is  a 
total  .separation  of  the  base  of  the  breast  from  its  attachment.  It  is  then 
comparatively  easy  to  remove  the  breast  from  its  connection  with  tlie  sub- 
cutaneous fatty  tissue  which  lies  between  the  manmiary  gland  antl  the  skin. 
If  the  patient  has  a  considerable  amount  of  fat  under  the  skin,  there  may  be 
a  surprising  absence  of  deformity  after  the  removal  of  the  breast,  especially 
if  subcutaneous  fat  is  somewhat  quilted  by  internipted  sutures  so  as  to 
make  a  projection  under  the  skin  to  take  the  place  of  the  gland  which  has 
been  removed.  In  a  very  thin  person  it  is  ciuestionable  whether  there  is 
anything  to  choose  between  removal  of  the  breast,  leaving  the  nipple,  or  the 

18 


^268 


ATLAS  OF  OPERATRE  GYN^XOLOGY 


total  reini)\'al  of  the  jihmd  with  the  skin  over  the  central  portion  of  it, 
containing  the  nipple.  Even  in  sucli  people,  however,  the  prejudice  against 
the  obvious  amputation  of  the  breast  by  the  removal  of  the  nipple  with  it 
may  be  so  great  as  to  lead  them  to  refuse  operation  altogether.  Naturally 
the  question  is  one  for  the  judgment  of  the  patient  and  physician  in  each 
individual  case.  Obviously  this  operation  lias  no  place  whate\'er  in  dealing 
with  growths  that  are  malignant  or  that  might  possibly  be  so. 

The  concluding  steps  of  the  operation  are  exactly  the  same  as  in  the 


Fig.  31. — Retraction  of  nipple  in  carcinoma  of  tlie  breast. 


plastic  resection,  except  that,  if  perfect  hsemostasis  be  secured,  drainage 
may  not  be  necessary.  If  the  latter  is  required,  the  author's  preference 
is  for  a  slender  rubber  drainage  tube  instead  of  the  glass  tube  advocated 
by  Warren. 

There  is  a  difference  in  the  dressing  after  the  operation.  The  support 
of  the  breast — or  the  breast  region,  rather,  from  which  the  mammary  gland 
has  been  removed — by  a  special  binder,  according  to  the  proposition  of 
Warren,  is  unnecessary;  so  that  the  ordinary  gauze  dressing  and  six-inch 
surgical  bandage  is  a  sufficient  dressing  after  this  operation. 


SURGERY  OF  THE  MAMMARY  GLAND 


'269 


(5)  Amputation  of  the  Breast  for  Malignant  Disease  Including 
A  Dissection  of  the  Axilla,  Removal  of  Glands  and  Fatty  Tissue 
and  Removal  of  Pectoral  Muscles  and  Fascia  (Figs.  31-33). — The 
feeling  of  hopelessness  with  regard  to  the  success  of  operation  on  a  mammary 


Fig.  32. — Pig.skin  appearance  of  breast  in  cancer. 


cancer  which  was  felt  in  the  last  generation  has  changed  to  one  decidedly 
hopeful  at  present:  Halstead's  forty-nine  cured  cases  out  of  one  hundred 
and  ninty-one  operations,  at  the  expiration  of  five  years,  is  sufficient  cause 
for  the  optimistic  feeling  entertained  by  the  profession  to-day. 


270 


ATLAS  OF  OPERATIM-:  (IVN. ECOLOGY 


We  owe  the  improved  results  to  the  work  of  .Moore,  Lister,  Kuster, 
Gross,  Halstead,  Willy  Meyer,  ^'olknl:um,  and  W.  Watson  C'heyne;  com- 
bined with  the  exjieriniental  and  lal)oratory  work  on  which  practical  pro- 
cedure was  based  and  develoiicd.  On  tliis  cooperative  plan,  nuidcrn  oper- 
ators have  perfected  a  technic  which  f^ives  promise  of  even  better  results 
in  the  future,  in  cases  .susceptible  of  a  possible  operative  cure.  Not  only 
has   improved  operative  technic  achieved  this  result,   but    iinproxcmcnl 


Fig,  33. — Cancer  of  breast,  ulcerative  stage. 

has  been  further  effected  by  a  standardization  of  the  lules  in  regard  to 
inoperal)ility  and  the  greater  care  exercised  in  differential  diagnosis. 

The  rules  laid  down  by  Handley  in  regard  to  inoperability  are  expressed 
as  clearly  as  possible.   The  condition  is  inoperable: 

(A)  When  the  primary  growth  has  become  attached  to  the  bony  thoiax. 

(B)  In  the  ])resence  of  cancer  en  ciiirassc,  or  of  subcutaneous  notlules 
or  skin  infiltration  situated  more  than  two  inches  from  the  primary  growth. 

(C)  If  there  is  a  fixed  mass  of  growth  in  the  axilla,  evidently  adherent 
to  its  walls. 

(D)  If  there  is  marked  oedema  of  the  arm. 

(E)  If  the  supraclavicular  glands  are  enlarged,  hard,  and  fixed. 

(F)  If  there  is  evidence  of  visceral  or  bone  metastases. 


SURGERY  OF  THE  MAMMARY  GL.\XD 


•271 


(G)  If  there  is  incurable  constitutional  disease — tuberculosis  or  dia- 
betes for  example— likely  to  be  fatal  in  a  few  years  at  most,  or  to  lead  to  a 
post-operative  fatality. 

■(H)  In  the  acute  forms  of  carcinoma. 

Patients  suffering  with  mammary  cancer,  when  referred  foi-  operation. 
are  divisiljle  into  five  more  or  less  clearly  defined  classes,  viz: 

(A)  Inoperable  cases  presenting  absolute  contra-indications  to  any 
form  of  operation. 


Fig.  34, — .lackson's  incision  for  amputation  of  the  breast. 

{B)  Inoperable,  but  presenting  the  indications  for  some  palliative 
operation. 

(C)  Clinically  malignant,  but  apparently  operal)le. 

(D)  Clinically  uncertain,  but  apparently  malignant. 

(E)  Clinically  benign,  but  found  at  the  time  of  operation  to  be  malig- 
nant— either  by  gross  examinations  of  the  cut  surface  of  the  tumor,  or  by 
the  microscopic  appearance  of  tissue  sections. 

All  modern  ojierators  adoj^t  the  technical  principles  laid  tlown  by 
Halstead.  but  there  are  many  minor  modifications  of  the  incision  and  of  the 
manner  in  which  the  tissues  are  removed  and  the  wound  is  closed. 

Incisions  are  made  differently  by  Halstead,  Handley,  Kocher,  Rodman, 


il'i 


ATLAS  OF  OPERATIVE  GYNECOLOGY 


Stewart,  Murphy,  Dawboru,  jMeyer,  Tansini,  Warren  and  Jackson  (Figs. 
34,35). 

The  author  prefers,  however,  and  has  almost  always  adopted  the  oper- 
ative technic  employed  by  John  B.  Deaver,  which  he  describes  as  follows: 

"The  incision  is  begun  on  the  arm  at  a  point  opposite  the  insertion  of 
the  i)ectoralis  major  nuiscle  at  the  level  of  the  anterior  edge  of  the  deltoid 
muscle  (Fig.  3G).  It  is  carried  upward  and  inward  well  on  to  the  shoulder 
to  a  point  about  two  inches  beyond  the  line  of  the  anterior  axillary  margin; 


Fig.  35. — Jackson's  incision  for  amputation  of  the  breast.     Operation  completed. 

and  then  is  continued  in  a  gradual  curve  (the  concavity  of  which  is  outward) 
to  within  two  inches  of  the  upper  margin  of  the  breast.  This  incision  is 
placed  well  within  the  line  of  the  anterior  axillary  margin  so  that  the  result- 
ing scar  will  not  cross  the  axilla  obliciuely  and  act  as  a  band  binding  the  arm 
to  the  side  of  the  chest  wall. 

"Two  incisions  are  made  to  diverge  from  the  lower  end  of  that  just 
described;  these  together  form  an  inverted  V,  the  limbs  of  which  are  made 
to  encircle  the  upper  segment  of  the  breast.  The  remaining  portions  of  the 
incision  are  marked  out,  without  cutting  through  the  whole  thickness  of  the 
skin  as  is  done  with  the  upper  portions  of  the  incision,  the  knife  being  merely 


SURGERY  OF  THE  MAMMARY  GLAND 


273 


permitted  to  cut  through  the  epidermis.  These  superficial  markings  simply 
continue  the  upjier  incisions  around  the  breast,  and  are  made  to  converge 
at  a  point  about  two  inches  below  its  lower  margin;  whence  a  single  incision 
is  carried  downward  and  inward   in  the  midline  of  the  rectus  abdominis 


/ 


f 


f 


Fio  36.— Showing  the  skin  incision.  The  dotted  lines  indicate  that  part  of  the  skin  incision  that  is  made  after 
the  axilliary  dissection  has  been  completed.  (Deaver  and  McFarland's  "The  Breast":  courtesy  of  P.  Blakiston  s 
Son  &  Co.) 

muscle  to  a  point  midway  between  the  tip  of  the  xiphoid  cartilage  and  the 
umbilicus.  The  portions  of  the  incision  above  the  breast  are  deepened 
until  the  fascia  covering  the  pectoralis  major  muscle  is  exposed.  The  skin 
flaps  outUned  in  this  manner  are  then  reflected  (Fig.  37),  the  median  one 
being  dissected  well  beyond  the  edge  of  the  sternum  and  in  an  upward 
direction  as  high  as  the  upper  border  of  the  clavicle.    The  anterior  portion 


••274 


A'1'I.AS  OF  OPKHA'rnE  GYNiECOLUGV 


of  the  deltoid  iimsele  is  exposed  in  this  dissection.  The  hiteral  flaj)  is  (Hs- 
sected  outward  and  backward  well  bej'ond  the  anterior  edge  of  the  lutissinius 
dorsi  muscle. 

"Having  reflected  the  flaps,  the  exposure  of  the  axillary  space  is  begun 


Fio.  .'!7. — The  upper  piirtinn  c,f  tin  .-kin  flnp-  lii.\  i  1.. .  i.  i .  II.  .  I  r.l  :rii.l  I  li.  Imniri  :il  ,1 1  ;m  liunnt  of  the  peotnralis 
major  muscle  has  heen  freed,  allowing  the  musric  to  retrad  tiowiiward  and  iiiwanl.  It  will  he  observed  that  tfie 
insertion  of  both  tlie  elavicular  and  sternal  lieads  of  llie  peetoralis  major  niusek-  }iave  been  freed  from  the  htimerus. 
The  cephalic  vein  is  .seen  in  its  norni.al  pesition  in  the  deltoper-toral  grottve.  (Deaver  and  McFarland's  "The 
Hreast":  courtesy  of  P.  Fiiakiston's  .Son  &  Co.) 

by  cutting  the  tendon  of  the  peetoralis  major  muscle  close  to  its  humeral 
attachment. 

"The  muscle  is  removed  in  toto.  When  the  muscle  is  freed  from  its 
insertion  on  the  humerus,  the  sternal  fibers  recede  downward  and  inward; 
the  clavicular  head,  on  the  contrary,  continues  to  obscure,  to  a  slight  extent, 
the  infraclavicular  region.    The  next  step  in  the  operation  is  to  separate 


SURGERY  OF  THE  MAMMARY  GLAND 


rhe 


the  latter  portion  of  the  muscle  from  its  line  of  origin  on  the  clavicle, 
cephalic  vein  is  in  danger  of  injury  at  this  stage  of  the  dissection. 

"The  second  layer  of  the  anterior  axillary  wall  consisting  of  the  pecto- 
ralis  minor  muscle  and  costocoracoid  membrane  is  now  completely  exposed. 

"The  index  finger  is  pushed  through   the   costocoracoid  membrane 


FiQ  3S— The  pectoralis  minor  muscle  has  been  elevated  on  the  finger:  the  cephalic  vein  is  seen  above  the 
tin  of  the  finKCr.  The  cephalic  vein  and  the  acromiothoracic  vessels  are  seen  piercing  the  costocoracoid  mem- 
Zne.  which^has  been  pie'iced  by  the  finger  in  elevating  the  nmsde  The  l°n\«''°^»'''^^^°d,  .=!""^''°''!,°;^^1J 
arteries  lie  posterior  to  the  finger,  so  that  there  is  little  danger  of  wounding  them  when  'hepeetoralisininor  muscle 
is  detached  from  the  coracoid  process  of  the  scapula.  (Deaverand  McFarland  s  The  Breast  .  courtesy 
P.  Blakiston's  Son  &  Co.) 

between  the  pectoralis  minor  muscle  and  the  acromiothoracic  artery,  and 
close  to  the  coracoid  process  of  the  scapula  (Fig.  38).  The  tendon  of  in- 
sertion of  the  muscle  is  then  raised  on  the  finger,  care  being  taken  to 
exclude  the  long  thoracic  artery  which  arises  behind  it.  and  the  tendon 
severed  with  a  jjair  of  blunt  scissors. 


276  ATLAS  OF  OPERATIVE  GYNECOLOGY 

"WTiile  strong  traction  is  made  to  lift  the  muscle  away  from  these 
structures,  the  tendon  of  the  muscle  is  grasped  with  a  jiair  of  ha'mostats 
to  catch  the  veins  which  traverse  its  substance,  and  a  branch  of  the  long 
thoracic  artery  which  frecjucntly  enters  it  near  its  scapular  attachment. 
All  danger  of  wounding  the  adjacent  vessels  is  obviated  by  using  the  finger 
as  a  guide  in  cutting  the  muscle.    The  axillary  space  is  now  fully  exposed. 

"Dissection  of  the  axilla  is  the  next  step  in  the  operation;  this  begins 
at  the  apex.  The  costocoracoid  membrane  is  cut  near  to  the  cla\'icle,  thus 
exposing  the  subclavius  muscle  and  the  deep  infraclavicular  triangle. 

"The  axillary  sheath  is  opened  with  a  sharp  knife,  as  near  to  the  apex 
of  the  axilla  as  possible,  and  is  stripped  from  the  subclavius  muscle  and  the 
axillary  vessels  from  above  downward.  This  is  best  accomjilished  by  gauze 
dissection,  wiping  the  areolar  tissue  and  the  contained  h'mphatics  away 
from  the  vessels  and  nerves. 

"Every  vestige  of  fibrous  and  fatty  tissue  must  be  removed,  especially 
from  the  upper  inner  portion  of  the  axillary  space.  This  dissection  exposes 
the  branches  of  the  axillary  artery  at  their  points  of  origin,  the  termination 
of  the  tributaries  to  theaxillary  vein,  and  the  terminal  portion  of  the  cephalic 
vein  (Fig.  39). 

"The  arteries  encountered  from  within  outward  are  the  superior 
thoracic,  the  alar  thoracic,  acromiothoracic,  long  thoracic,  and  subscapular. 
The  superior  thoracic,  usually  a  small  vessel,  arises  high  in  the  axilla,  so 
that  it  is  usually  bej'ond  the  area  of  dissection. 

"The  other  vessels  named,  with  the  exception  of  the  acromiothoracic 
and  the  subscapular,  are  to  be  ligated  and  cut.  As  a  rule,  we  preser\e  the 
latter  vessel,  although  its  sacrifice  may  be  necessary  in  order  that  the  tissues 
surrounding  it  may  be  removed. 

"The  veins  accompanying  these  arteries,  except  the  cephalic  vein,  are 
tied  near  their  terminations  and  cut.  The  anterior  thoracic  (external  and 
internal)  nerves  have  been  severed  in  reflecting  the  pectoral  muscles. 

"With  the  completion  of  the  foregoing  tlissection  as  far  outward  as 
the  origin  of  the  subscapular  artery,  it  remains  to  remove  the  fascia  and  fat 
surrounding  this  vessel  and  its  branches.  The  dissection  begins  above  the 
teres  minor  muscle,  is  carried  downward  removing  the  fascial  covering  of 
the  muscle,  the  teres  major,  subscapularis,  latissimus  dorsi,  and  serratus 
magnus  muscles.  In  cleansing  the  latter,  care  must  be  taken  to  preserve 
the  external  thoracic  nerve  (nerve  of  Bell)  which  runs  over  it  in  the  line  of 
the  mid-axilla.  The  middle  or  long  subscapular  nerve  which  supplies  the 
latissimus  dorsi  muscle  must  be  preserved.  This  is  not  difficult  to  do  if 
gauze  dissection  is  adhered  to  in  cleansing  the  costal  surface  of  the  muscle. 

"The  dissection  of  the  axilla  being  finished,  the  lower  part  of  the  field 
of  operation  is  exposed  by  continuing  the  reflection  of  the  skin  flaps  (Fig. 


SURGERY  OF  THE  MAMMARY  GLAND 


277 


40).  The  incisions  outlined  on  the  skin  in  the  manner  described  above  are 
deepened  until  the  deep  pectoral  fascia  is  exposed.  Dissection  of  the  lateral 
flap  is  made  fifst,  and  exposes  the  lower  digitations  of  the  serratus  mag- 


FiG.  39. — The  pectoralis  minor  muscle  has  been  freed  from  the  coracoid  process  of  the  scapula.  The  apex  of  the 
axilla  has  been  cleansed,  and  the  contents  are  seen  reflected  downward  and  outward.  In  the  upper  portion  of  the 
wound  the  clavicle  and  subelavius  muscle  are  visible  and  emerging  from  beneath  them  are  the  axillary  vessels 
and  nerves.     iDeaver  and  McFarland's  "The  Breast";  courtesv  P.  Blakiston's  ."^on  &  Co.l 

nus  muscle  and  some  of  the  upper  digitations  of  the  external  oblique 
muscle;  as  well  as  the  outer  half  of  the  upper  portion  of  the  sheath  of  the 
rectus  abdominis  muscle.     A  slight  amount  of  bleeding,  from  the  lateral 


-278 


ATLAS  OF  OPERATIVE  GYNiECOLOC.Y 


branches  of  the  intercostal  arteries  is  encountered  (hiring  the  reflection  of 
the  hiteral  thip. 

"The  median  flap  is  now  dissected  well  beyond  the  edge  of  the  sternum. 
No  attention  is  paid  to  the  bleeding  that  results,  at  this  time,  from  the 


i 


Fig.  40. — The  axilliary  dis.^erti(in  is  conipletoil  with  the  exception  of  that  portion  in  tlie  region  of  the  lower 
posterior  axilliary  fold.  The  skin  flaps  have  been  roinpletely  reflected.  (Deaver  and  MeFarland's  "The  Breast": 
courtesy  P.  Blakiston's  Son  &  Co.) 

perforating  branches  of  the  internal  mammary  artery,  as  these  branches 
will  be  cut  a  second  time  when  the  pectoralis  major  muscle  is  removed. 
The  breast  is  now  grasped  in  the  left  hand  and  traction  is  exerted,  putting 
the  pectoral  muscles  on  the  stretch;  they  can  then  easily  be  freed  from  their 
attachments  to  the  chest  wall.  The  axillary  contents,  the  i:iectoral  muscles, 
and  the  breast  are  removed  as  one  mass  (Fig.  41). 


SURGERY  OF  THE  MAM.MAItY  GLAND 


279 


"In  cases  in  which  the  carcinoma  involves  the  lower  outer  quadrant 
of  the  breast,  the  sixth,  seventh,  and  eighth  digitations  of  the  serratus 
magnus  muscle  must  be  reni()\ed. 


lie.  41. —  Ihc  breast  and  pectciriil  jiiiisilcs  an-  jij  the  grasp  of  the  left  haiui  ami  arc  bciag  dissecteil  from  the 
chest  wall.  It  will  be  observed  that  the  upper  portion  of  the  rectus  abdominis  sheath  has  been  removed.  The  long 
thoracic  nerve  remains  intact,     (Deaver  and  McFarlami's  "The  Rreast  ":  courtcsv  P.  Blakiston's  Srtn  i!t  Co.) 


"Removal  of  the  fascia  covering  the  upper  digitations  of  the  external 
oblique  muscle,  together  with  the  upper  part  of  the  anterior  rectus  sheath, 
completes  the  dissection  (Fig.  42). 


280 


ATLAS  OF  OPERATI\'E  GYNECOLOGY 


"The  few  bloeding  points  are  ligatcd  with  catgiit.  A  counter  incision 
is  made  in  the  ]iosteri<)i'  Hap,  in  sucli  position  that  with  the  patient  lying 


Fig.  42. — Dissection  completed.  The  long  thoracic  and  long  subscapular  nerves  are  well  shown  The  serra- 
tus  magnus  muscle  has  in  part  been  removed.  The  illustration  shows  that  the  subscapular  vessels  have  been  re- 
moved; this  is  unnecessary  in  the  majority  of  instances.  The  fascial  sheaths  covering  the  external  oblique  and  rec- 
tus abdominis  muscles  have  been  in  part  removed.  (Deaver  and  McFarland's  "The  Breast";  courtesy  P.  Blakis- 
lon's  Son  &  Co.) 

on  her  back  the  opening  will  be  in  a  dependent  position  and  just  in  front 
of  the  free  edge  of  the  latissimus dorsi  muscles;  in  some  instances  the  opening 
is  carried  through  the  muscle. 


SURGERY  OF  THE  MAMMARY  GLAND  281 

"A  fenestrated  drainage  tube,  one-(iuarter  inch  in  diameter,  is  placed 
in  the  axillary  space,  care  being  taken  that  it  does  not  come  in  contact  with 
the  axillary  vessels  and  nerves.  Having  determined  the  proper  position  of 
the  tube,  it  is  anchored  to  the  skin  edges  of  the  counter-opening  with  a  single 
suture  of  silkworm  gut. 

"Before  closing  the  wound,  a  final  examination  is  made  for  bleeding 
points,  and  hot  compresses  are  applied  to  arrest  the  slight  oozing  that  occurs 
in  all  cases.  The  transudation  of  serum  incident  to  the  healing  process, 
together  with  the  slight  oozing  of  blood,  justifies  the  employment  of  drain- 
age during  the  first  twenty-four  hours  after  operation.  A  free  exit  for  the 
material  that  collects  in  the  axilla  minimizes  the  danger  of  infection,  hastens 
the  healing  process,  and  also  minimizes  the  strength  of  atlhesions  that  form 
in  the  axilla. 

"The  arm  is  now  adducted  and  the  flaps  approximated  with  three  or 
more  interrupted  sutures  of  silkworm  gut,  the  number  depending  upon  the 
amount  of  traction  necessary  to  bring  the  incisional  edges  together.  The 
wound  can  be  closed  primarily  in  the  great  majority  of  instances  without 
over-stretching,  if  the  flaps  are  sufficiently  undermined." 

The  margins  of  the  skin  are  united  with  interrupted  sutures  of  fine 
silkworm  gut,  at  rather  wide  intervals,  catgut  stitches  intervening. 

Sterile  pads,  made  of  non-absorbent  cotton  covered  with  several  thick- 
nesses of  gauze,  are  placed  in  the  axilla  in  sufficient  number  to  hold  the  arm 
at  an  angle  of  approximately  70  degrees.  The  incision  is  covered  with 
sterile  gauze  and  a  figure-of-eight  bandage  is  applied  to  include  the  shoulder 
of  the  affected  side,  the  axilla,  and  the  chest.  This  bandage,  which  should 
be  six  inches  in  width,  is  composed  of  eight  thicknesses  of  gauze. 

The  preparation  of  the  field  of  operation  is  conducted  on  the  same  jirin- 
ciples  as  the  preparation  of  the  abdomen  for  a  section.  The  patient  receives 
a  full  bath  the  night  before  operation,  is  clatl  in  clean  night  clothes,  and  put 
into  a  bed  with  clean  sheets. 

Directly  before  the  operation  the  skin  is  cleansed  by  a  soap  solution 
and  soft  pledgets  of  absorbent  cotton,  rubbing  away  from  the  site  of  the 
incision.  The  axilla  is  shaved.  This  is  followed  by  ether  and  then  by 
phenoco  solution  along  the  area  to  be  incised.  This  material  is  lightly  wiped 
off  before  the  incisions  are  made,  in  order  to  prevent  excessive  irritation  of 
the  edges  of  the  skin  wound  after  the  conclusion  of  the  operation.  The 
author  prefers  a  dissecting  board  for  the  corresponding  arm,  padded  and 
covered  with  a  sterile  gauze  bandage,  the  wrist  being  bound  to  it  by  a  light 
gauze  bandage. 

The  field  of  operation  is  jM-otected  in  the  usual  manner  by  sterile  towels 
surrounding  it;  extra  towels  are  so  arranged  as  to  jirotect  the  patient's 
mouth  and  nose  and  the  anaesthetist  is  prepared  like  one  of  the  surgical 
assistants  with  sterile  cap,  gown,  and  gloves. 


0S2  ATl.AS  OF  OPERATIVE  GYN.ECOUXiV 

On  acrount  of  the  long;  exposure  of  the  unprotected  chest,  the  operat- 
ing room  should  be  unusually  warm,  and  as  the  patient  is  transported 
from  the  operating  room  to  her  bed  special  precautions  must  be  taken  to 
]ire\ent  a  chill. 

The  after-treatment  of  the  operation  may  have  to  Ijc  that  of  any  serious 
surgical  procedure— artificial  heat  under  an  electrical  cabinet,  stimulating 
drugs,  and  possibly  intra venus  salt  solution. 

The  anaesthesia  should  be  general,  and  the  liest  residts  have  been  secured 
by  the  drop  ether  method.  As  soon  as  the  patient  recovers  from  tlie  anaes- 
thetic, she  is  arranged  in  l)ed  in  a  semi-recumbent  posture  with  tlie  arm 
corresponding  to  the  operated  side  supported  on  jiillows.  The  dressing  of 
the  woimd  is  renewed  in  twenty-four  hours;  the  drainage  tube  remo\ed  in 
one  to  three  days,  dependent  on  the  amount  of  ilischarge.  The  removal  of 
the  stitches  is  begun  on  the  fom-th  or  fifth  day  and  completed  within  seven 
to  ten  days.  The  patient  should  be  able  to  get  out  of  bed  by  the  end  of  a 
week  and  often  sooner,  with  the  arm  sujjported  by  a  sling. 

Early  movement  of  the  arm  should  be  encouraged  to  avoid  disability 
as  much  as  possible.  It  is  astonishing  to  see  what  mobility  the  arm  possesses 
after  the  removal  of  the  pectoral  muscles. 

CEilema  which  may  occur  shortly  after  the  operation  is  apt  to  disappear; 
but,  if  it  makes  its  appearance  only  later  on, it  is  possibly  a  sign  of  recurrence. 

As  soon  as  the  wound  is  healed,  the  patient  should  be  subjected  to 
X-ray  treatment  at  the  hands  of  a  specialist,  as  a  preventive  treatment. 
Local  recurrences  should  be  carefully  watched  for  and,  if  small  in  area, 
might  be  aborted  by  the  use  of  the  actual  cautery. 

The  operative  treatment  of  recurrent  growths  is  hoi)eless,  and  should 
be  avoided  unless  the  removal  of  sloughing  masses  may  contribute  somewhat 
to  the  patient's  comfort. 

Recurrence  or  extension  in  the  supraclavicular  gland  cannot  be  dealt 
with  successfully  by  operation,  unless  the  glands  are  small  in  size,  few  in 
number,  and  easily  removed. 

The  only  hope  for  extensive  regional  recurrences  (and  that  is  a  forlorn 
one)  is  the  use  of  X-ray  and  radium.  If  there  is  not  recurrence  within  a 
year,  there  is  great  hope  of  permanent  cure ;  for  usually  recurrence  manifests 
itself  within  the  first  six  months. 

If  the  patient  shows  no  sign  of  recurrence  in  three  years,  perma- 
nent cure  is  pretty  certain.  It  is  not  so  necessary  to  observe  the  five-year 
interval  as  it  is  in  cancer  of  the  uterus,  but  late  recurrences  beyond  the 
five-year  period  have  been  recorded,  both  regionally  and  as  metastases 
to  distant  organs. 

(6)  Pl.\stic  Operations  on  the  Breast. — A,  Operative  Treatment 
for  Inverted  Nipple  {Umbilication  of  Nipple). — The  term  "inverted  nipple" 


SURGERY  OF  THE  MAMMARY  GLAND 


283 


is  employed  when  the  nipple  is  represented  by  a  sort  of  crater-like  depres- 
sion; the  word  "umbilication"  is  used  when  the  nipple  projects  some- 
what in  the  center  of  a  depression  below  the  level  of  the  skin  over  the 
rest  of  the  breast. 

Operations  for  these  conditions  have  been  devised  by  Axford,  Kehrer, 
and  Williams.  The  principle  of  these  operations  is  the  same.  It  consists 
of  excising  crescentic-shaped  flaps  of  skin  and  fat  down  to  the  fascia,  around 
the  nipple  outside  the  areola,  and  then  either  puckering  the  fascia  by  a 
circular  purse-string  suture  as  in  Axford's  technic,  or  in  uniting  the  skin, 
after  excision  of  crescentic  flaps  around  the  nipple,  so  as  to  exert  traction 


Fig.  43 — Virginial  hypertrophy  of  the  breasts.     (Deaver  and  McFarland's  "The  Breast' '; 
courtesy  P.  Blakiston's  Son  &  Co.) 

upon  the  depressed  nipple  and  to  build  up  a  wedge  of  cicatrix  and  exudate 
around  its  base.  In  both  kinds  of  operation,  the  nipple  is  seized  by  a  vol- 
sellum  forceps  and  pulled  out  before  the  sutures  are  inserted. 

For  true  inversion  of  the  nipple  these  operations  are  not  always  success- 
ful, and  for  umbilication  of  the  nipple  they  are  very  rarely  necessary.  If  a 
persistent  effort  is  made  to  draw  out  the  nipple  by  suction  with  a  breast 
pump  for  several  weeks  before  the  woman's  expected  confinement,  a  plastic 
operation  on  the  nipples — a  so-called  mamillaplasty — is  almost  never 
necessary.  I  have  never  seen  a  case  myself  in  which  operation  was  required, 
in  order  to  enable  the  woman  to  nurse  her  baby:  which  is  the  only  purpose 
for  which  such  operations  should  be  considered.  There  is  no  occasion  for 
surgical  interference  with  the  nipples  for  purely  aesthetic  reasons,  as  this 

19 


384 


ATLAS  OF  OPERATIVE  GYNECOLOGY 


portion  of  the  breast  is  not  exposed  to  the  public  gaze.    If  operative  treat- 
ment is  decided  upon,  it  can  be  performed  under  local  anaesthesia. 


Fio.  44. — Bilateral  hypertrophy  of  breasts.     (Dr,  \V.  T,.  Clark.) 


Fig.   45.— Hypertrophy  of  the  brea.^t.      (Dr  \V.  I,.  Clark.1 

In  these  days,  however,  of  successful  artificial  feeding  of  an  infant,  it 
must  be  a  rare  case  indeed  in  which  surgical  treatment  of  nipples  that  do 
not  respond  to  persistent  traction  is  really  necessary  or  desirable. 


SURGERY  OF  THE  MAM.MARY  GLAM)  -285 

B.  Operative  Treatment  of  Mammary  Hypertrophy  (Figs.  43-46). — 
A  degree  of  mammary  hypertrophy  demanding  operati\e  treatment  is  rare. 
Deaver  and  MacFarland  were  able  to  collect  only  one  hundred  and  eighty- 
two  cases.  Before  resorting  to  operation,  several  facts  must  be  carefully 
considered:  (1)  The  disease  often  affects  young  women  from  puberty,  and 
the  mutilation  and  the  disability  as  regards  lactation  must  be  taken  into 
account.  (2)  The  disease  not  infrequently  undergoes  a  spontaneous  cure, 
as  mj^sterious  as  its  occurrence.  (3)  Lactation  sometimes  results  in  invo- 
lution of  the  hypertrophied  gland.  All  these  considerations  must  be  care- 
full}'  weighed. 

In  exceptional  cases,  however,  there  is  no  room  for  doubt  as  to  the  nec- 
essary treatment — if  the  size  and  weight  are  so  enormous  as  to  make  loco- 


Flu.  40. — Hypertrophy  of  the  breast  after  operation,     (Dr.  W.  L    Clark.) 

motion  imijossible;  or  if  the  drain  on  the  woman's  s^ystem,  for  the  nutrition 
of  the  huge  mass  of  tissue  constituting  the  breasts,  results  in  extreme  weak- 
ness and  emaciation  of  the  individual;  or  if  the  patient  demands  the  removal 
of  the  hypertr()]:)hied  breast,  or  breasts,  irrespective  of  the  possibility  of 
spontaneous  cure  or  of  future  lactation,  the  surgeon  need  not  hesitate  to 
perform  the  operation. 

The  usual  surgical  treatment  is  amputation,  but  it  is  possible  to  get 
rid  of  the  superfluous  size  and  weight  of  the  breast  without  disfigurement  to 
the  patient  and  with  a  possibility  of  preserving  enough  breast  tissue  perhaps 
to  permit  lactation.  This  can  be  accomplished  ])y  making  a  double  ellii)tical 
incision,  through  the  skin,  lea\'ing  the  nipple  intact  in  the  middle  of  the  area 


^286  ATLAS  OF  OPERATIVE  GYNECOLOGY 

marked  out.  If  the  median  upper  bar  of  this  eUiptical  incision  comes  close 
to  the  nijijile  and  curves  quite  sharply  downward  both  to  the  inner  and  the 
outer  sides,  and  if  all  the  superfluous  skin  above  that  jjoint  is  removed,  it 
is  possible  to  remove  a  large  flap  of  the  enormously  stretched  skin  over  the 
upper,  outer  surface  of  the  breast,  and  to  imite  the  woimd  in  such  a  manner 
that  the  sear  is  not  visible  in  ordinary  evening  dress.  The  bulk  of  the  breast 
is  removed  as  in  the  Warren  operation,  but  a  large  area  of  skin  is  necessarily 
taken  away  below  the  nipple  with  the  superfluous  portion  of  the  breast. 

If  both  breasts  must  be  operated  upon,  which  is  necessary  in  the  major- 
ity of  cases,  it  may  be  advisable  to  remo\e  or  to  ojjerate  upon  one  at  a  time, 
in  order  to  lessen  the  severity  of  the  operation ;  also  because  sometimes  the 
removal  of  one  breast  results  in  the  involution  of  the  other  one. 

C  Operalion  for  Pendulous  Breast;  Mastopexy. — Pendulous  breasts 
without  hypertrophy  almost  never  require  operati\'e  treatment.  A  properly 
made  brassiere  will  suffice  for  their  support,  but  there  have  been  recorded 
cases  in  which  an  operation  seemed  necessary.  The  easiest  way  to  dispose 
of  the  difficulty  is  by  amputation,  but  operations  have  been  devised  for  the 
correction  of  the  pendulous  breasts  without  mutilation.  These  operations 
consist  in  fixation  of  the  mammary  gland  to  the  deep  fascia  of  the  ]iect oralis 
major  or  to  the  costal  cartilages,  as  in  the  operation  described  by  Ciirard. 

The  operation  is  begun  by  the  Thomas-\^'arren  incision.  The  breast 
is  then  dissected  off  from  the  fascia  of  the  pectorahs  major  for  something 
like  half  the  extent  of  its  base. 

Having  been  displaced  upward  as  far  as  desired,  and  possibly  reduced 
somewhat  in  size  by  the  removal  of  a  portion  of  the  breast  tissue,  the  fixa- 
tion is  accomplished  by  either  silk  or  chromic  gut  sutures,  fastening  the 
breast  to  the  costal  cartilages  or  cartilage  as  high  as  necessary,  and  utilizing 
the  fascia  of  the  i)ectoralis  major  for  the  outer  segment  of  the  breast.  Suc- 
cessive rows  of  interrupted  sutures  would  seem  to  me  the  most  efficient  way 
of  fixing  the  breast  in  its  new  position,  although  I  have  no  personal  expe- 
rience with  the  operation  and  do  not  know  any  of  my  colleagues  who  have. 

After  the  operation  it  would  obviously  be  necessary  to  support  the 
breast  by  a  broad  bandage  encircling  the  chest  below  the  mammary  gland, 
and  supported  by  straps  over  the  shoulder. 


INDEX 


Abdominal  section,  after-treatment  of,  251 
for  acute  ana-mia,  253 
for  nausea,  251 
for  shock,  252 
for  tympanites,  251 
galvanization,  252 
re-opening  of  abdomen,  252 
for  vomiting,  252 

internal  bleeding,  diagnosis  of,  252 
Murphy  drip  proctoclysis,  251 
preparation  for,  13 
catheterization,  19 
cleansing  the  skin,  13 
Hirst's  method,  14 
MacDonald's  method,  18 
Martin's  method,  18 
thrombosis  of  mesenteric  veins  complicat- 
ing, 252 
wound,  closure  of,  25 
Abscess,  mammar>',  surgical  treatment  of,  253 
After-treatment  of  abdominal  section,  251 
of  complete  tear  operation  of  perineum,  46 
of  plastic  operations,  252 
Air-cushion  for  operating  table,  5 
Alexander  operation  for  retroversion  of  uterus, 

disadvantage  of,  104 
Anipmia,  acute,  treatment  of,  following  opera- 
tion, 253 
AnEBSthetics,  19 
Antepartum  fcetonietry,  248 
Anterior  vaginal  hysterotomy,  127 
Anus  vestibularLs,  operation  for,  149 

Bandl's  operation  for  ureteral  fistula,  101 

Bartholin's  gland,  removal  of,  154 

Bleeding,    internal,    after-abdominal    section, 

diagnosis  of,  252 
Breast,  amputation  of,  for  hypertrophy,  285 
for  malignant  disease,  269 
after-treatment,  282 

X-ray,  282 
anaesthesia,  282 
Deaver's  technic,  272 

closure  of  wound,  281 
dissection  of  axilla,  276 
dressing  over  wound,  281 
incision,  the,  272 
insertion  of  drainage  tube,  2S0 
removal  of  breast,  278 

of  pectoralis  major  muscle,  274 


Breast,  amputation   of  for  malignant  disease, 
Handley's  rules  regarding  inopera- 
bility,  270 
oedema,  occurrence  of,  after,  282 
preparation  of  patient  for,  281 
recurrent  growths,  282 
for  non-malignant  conditions,  265 
anaesthesia  in,  267 
dressing  and  after-treatment,  267 
preparation  for  operation,  266 
technic  of,  265 
subcutaneous,  with  preservation  of  nipple, 
267 
dressing  after  operation,  268 
Thomas-Warren  incision,  267 
pathological  conditions  of,operations  for,cys- 
tic  or  sohd  tumors,  257 
papillomata,  257 
possibility  of  lacteal  fistula,  257 

of  malignancy,  257 
supernumerary  glands,  257 
surface  growths,  257 
Thomas-Warren  incision,  258,  260 
pendulous,  operation  for,  286 

technic  of,  286 
plastic  operations  on,  282 
for  hypertrophy,  285 
for  inverted  nipple,  282 
for  pendulous  breast,  286 
resection  of,  260 

Cesarean  section,  225 
conservative,  225 

hypodermics  of  pituitary   extract    and 

ergot  ine  during,  226 
removing  the  feet  us,  226 
separating  the  placenta,  228 
suture  of  uterine  wall,  '226 
technic,  225 
extraperitoneal,  235 

danger  of  infection,  237 

injections  of  pituitary  extract  and  ergo- 

tine,  246 
mortality  statistics,  comparative,  235 
panhysterectomy  with,  235 
Sellheim's  scoop,  237 
technic,  236 

delivery  of  head,  237 
of  placenta,  237 
suturing,  237 

iS7 


'288 


INDKX 


Csesarean  section,  Form's,  234 
in  severe  infection,  234 
supravaginal  amputation  of  uterus  with 
extraperitoneal  fixation  of  cer- 
vical stump,  234 
with  peritonealization  anil  sinking 
of  cervical  stum|),  234 
Saenger's,  22r) 

superiority  of,  to  imlnotomy,  246 
tympanites  following,  treatment  of,  2.')1 
Cancer  of  breast,   Handley's   rules   regarding 
inoiKMability  of,  270 
operation  for,  209 
Carcinoma  of  uterus,  importance  of  early  diag- 
nosis and  treatment,  200 
panhysterectomy  for,  197 
Catheter  for  abdominal  section,  19 

for  vaginal  o|H'rations,  12 
C'atheterization  following  operation  for  vesico- 
vaginal fistula',  94 
in  vaginal  operations,  12 
Cervical  canal,  dilatation  of,  120 

anterior  vaginal  hysterotomy,  127 
electrolysis  in,  128 
instrumental,  126 

for  mechanical  dysmenorrluva,  120 
for  sterility,  120 
in  pregnancy,  127 
Cervix,  injuries  of,  85 
oijerations  for,  85 
amputation,  85 

Hegar's,  85 
caution  in  inserting  sutures,  85 
Emmet  trachelorrhaphy,  85 
suture  material  in,  80 
Clamp,  ISigwart,  S 
Somers,  0 
Wertheim,  7 
Cleveland's  dilator,  10 
(.'losure  of  abdominal  wound,  25 
Coffey  operation  for  retroversion  of  uterus,  dis- 
advantages of,  106 
Colpodeisis,  95 
Continence,  establishing  of,  without  a  urethra, 

96 
(Cystic  or  solid  tumors  of  breast,  excision  of,  257 
Cystoeele,  avoidance  of,  5() 
operation  for,  70 

alterative  procedures,  77 
avoidance  of  hemorrhage,  71 
deUvery  of  uterus,  70 
gauze  drainage  avoided,  72 
ha>matomata  follow'ing,  71 
in  young  women,  77 
Goffe's,  77 


Cystoeele,   operation   for,    in   young    women, 

Hirst's,  77 
Mayo  Clinic  method,  77 
narrowing  of  vagina,  71 
protrusion  of  fundus  uteri,  72 
separation  of  bladder  and  vagina,  70 
Watkins',  71 

Dakin's  irrigating  lluid  in   iiiMinmary  abscess, 

254 
Deaver's  oi)cration  for  amiml.-ition  of  breast  in 

malignant  disease,  272 
Dewees'  dilator,  U) 
Dilatation  of  cervical  canal,  120 
Dilators,  9 

Cleveland's,  10 

Dewees',  10 

for  dilatation  of  cervical  canal,  I'JO,  127 

J.  C.  Hirst's,  10 
Drainage  in  salpingectomy,  101 

wounds,  closure  of,  25 
Dudley  operation  for  anteflexion  of  uterus,  US 

for  ureteral  fistula,  102 
Dysmenorrhiea,  mechanical,  dilatation  of  cer- 
vical canal  for,  r20 

Ectopic  gestation,  salpingectomy  in,  1()0 
Electrolysis  in  dilatation  of  cervical  canal,  128 

for  development  of  uterus,  1*28 
Emmet  trachelorrhaphy,  85 
Equipment  and  preparation  for  operations,  1 
air  cushion,  5 

Heineberg's  pan  and  sieve,  7 
instrument  tray  and  stand,  5 
instruments,  (J 
clamjjs,  7 

Somers',  0 
dilators,  9 
forceps,  7,  8 
Gelpi's  retractor,  7 
hooks,  7 
metranoicter,  9 
operating  room,  1 
patient,  the,  6 
tables,  4 
Exsection  of  vulvar  nerves,  153 

Fibroid  tumors  of  rountl  ligament,  dissection 

of  inguinal  canal  for  removal  of,  153 
Fistula",  rectovaginal,  97 
ureteral,  101 

operation  for,  101 
Bandl's,  101 
Dudley  s,  102 
Mackenrodt's,  102 
Schede's,  101 


INDEX 


289 


Fistulae,  ureteral,  vaginal  operation  for,  101 
of  urogenital  tract,  94 
operations  for,  94 
vesicovaginal,  94 

between  vagina  and  bladder,  94 
following  labor,  94 
operation  for,  94 

accidental  stitching  of  ureter  in,  97 
catheterization  following,  94 
colpocleisis,  95 

incision  into  anterior  bladiler-wall,  96 
intravesical  hemorrhage  after,  97 
opening  Douglas's  pouch,  96 
persistence  of  incontinence  after,  97 
rectovaginal  fistula,  97 
restoration  of  urethra,  96 
separation  of  vagina  from  bladder,  96 
transverse  incision  over  pubis,  96 
within  cervical  canal,  97 
Foetometrj',  antepartum,  248 
Forceps,  7 

lion-jawed,  9 
Fundus  uteri,  protrusion   of,   following  inter- 
position operation,  72 

Galvanic  current  for  tympanites  after  abdomi- 
nal section,  252 
Gelpi's  retractor,  7 
Gland,  vulvovaginal  or  Bartholin's,  removal  of, 

154 
Glands  of  breast,  supernumerary,  removal  of, 

257 
Goffe's  dissector,  8 

Gonorrhoeal  infection,  salpingectomy  in,  160 
GjTiatresia,  operations  for,  140 

making  of  artificial  vagina,  149 

with  absence  of  vagina  and  uterus,  141 

with  genital  canal  preserved  above  site  of 

atresia,  141 
with  retained  blood  in  genital  tract,  140 

Haemostats,  T-shaped,  9 

Hand  cleansing  before  operation,  19 

Handley's    rules    regarding    inoperability    of 

cancer  of  breast,  270 
Heineberg's  pan  and  sieve,  7 
Hemorrhage,   avoidance   of,   in   operation   for 
cystocele,  71 

intravesical,  following  operation  for  vesico- 
vaginal fistula,  97 
Hermaphroditism,  operations  for,  154 
Hernia,  closure  of  inguinal  canal  for,  153 
Hirst's  dilator,  10 

operating  table,  4 
Hooks,  blunt,  7 


Hypertrophy,  mammary,  o|ierative  treatment 
of,  285 
conditions  necessitating,  285 
Hysterectomy,  184 

cuneiform,  at  fundus  of  cornua,  201 

for  carcinoma  of  uterus,  197 

for  fibroid  tumors,  173 

for  removal  of  malignant  growths,  197 

supravaginal,  184 

extraperitoneal,  by  vaginal  route,  207. 

technic  of,  207 
removal  of  both  ovaries,  184 
technic  of,  184 
vaginal,  217 

extended,  for  cancer,  217 
ligature  method  of  securing    broad    liga- 
ment, 217 
preparations  for  abdominal  section  in,  218 
Hysterotomy,  anterior  vaginal,  for  digital  ex- 
ploration of  uterine  cavity,  127 

Incontinence  of  urine  following  interposition 

operation,  72 
Inguinal  canal,  closure  of,  for  hernia,  153 

dissection  of,  for  removal  of   fibroid  tu- 
mors of  round  hgament,  153 
Injuries  to  pelvic  floor  and  perineum,  immedi- 
ate repair  objectionable,  30 
objections  to  intermediate  operation 

not  valid,  31 
repair  of,  30 
Instrument  tray  and  stand,  5 
Instruments,  6 
catheters,  12 
clamps,  7 
dilators,  9 
forceps,  7 

lion-jawed,  9 
Gelpi's  retractor,  7 
ha>mostats,  T-shaped,  9 
Heineberg's  pan  and  sieve,  7 
hooks,  7 

listed  by  National  Defense  Committee,  6 
metranoicter,  9 
Somers'  clamp,  6 
Interposition,  cuneiform  hysterectomy  in  cases 
of,  201 
operation,  70 

avoidance  of  hemorrhage,  71 
delivery  of  uterus,  72 
fastening  of  fundus  uteri  to  vaginal  wall,  71 
incontinence  of  urine  following,  72 
narrowing  of  vagina,  71 
separation  of  bladder  and  vagina,  72 
Inversion  of  uterus,  1 18 


•290 


INDEX 


Inverted  nipple,  operative  treatment  for,  282 

Lacerations  of  genital  canal,  operation  for,  25 
Lamp  for  emergency  night  work,  1 
Loewenstein  tables,  5 

Mackenrodt's  operation  for  ureteral  fistula,  102 
Mammary  abscess,  i)leural  involvement  in,  2,56 
surgical  treatment  of,  2.53 
amputation,  2.5(5 
Dakin's  irrigating  fluid  for,  2.54 
digital  method,  254 
early  operation  advised,  256 
in  convalescence,  256 
irrigation  method,  254 
gland,  hypertrophy  of,  operative  treatment 
of,  285 
surgery  of,  25.3 
Mastopexy,  286 
Metranoicter,  9 
Murphy  drip  proctoclysis,  251 
Myoma,  cervical,  myomectomy  for,  175 
Myomectomy,  173 
abdominal,  173 
adhesions  following,  174 
arguments  for  and  against,  173 
iluring  pregnancy,  174 
for  infected  myomata,  176 
technic  of  operation,  174 
vaginal,  175 

treatment  of  tumor  cavity  after,  175 

Nausea,  treatment  of,  after  abdominal  section, 

251 
Nerves,  vulvar,  excision  of,  153 
Nipple,  inverted,  operative  treatment  for,  264, 

282 
Nymphomania,  operaticm  for,  1.53 

Oophorectomy,  169 
partial,  170 

union  of  wound  in,  170 
Operating  room,  1 

color  or  walls,  4 

designed  for  teaching,  1 

emergency  night  work,  1 

not  designed  for  teacliing,  3 

University  maternity  clinic,  1 
tables,  4 

air  cushion  for,  5 

for  Wertheim  operation,  5 

Hirst's,  4 

Loewenstein 's,  5 
technic,  25 


Ovarian  cystic  tumors,  removal  of,  169 

intrahgamentary  cysts  without  pedi- 
cle, 170 
involvement  of  both  ovaries,  169 
suspension  of  uterus,  170 

Ovary,  removal  of,  169 

Panhysterectomy,  197 

disinfection  of  vagina  before,  197,  200 
extended,  for  carcinoma  of  uterus,  197 
after-treatment,  200 
during  pregnancy,  201 
Hirst's  technic,  199 
importance  of  early  diagnosis,  200 
mortality  from,  198 
technic  of,  197 
Wertheim,  197 
with  ca'Sarean  .section,  235 
Papillomata  of  breast,  removal  of,  257 
Patient,  prejmration  of,  6 
Pendulous  breast,  operation  for,  286 
Perineorrhaphy,  after-treatment  of,  31 

rational,  30 
Perineum,  central  perforation  of,  operation  for, 
47 
complete    tear   of,    operation    for,    thniugh 
sphincter  ani,  46 
after-treatment,  46 
contingencies,  47 
following  failure  of  previous  attempt, 

47 
preparation  for,  46 
steps  of  operation,  46 
suture  material,  46 
with  involvement  of  other  structures,  46 
Piper's  method  of  irrigating  infected  .sinuses 

and  drainage  tracts,  2.54 
Plastic  operations,  after-treatment  of,  2.52 
on  breast,  282 
resection    (see   Thomas-Warren    operation), 
of  breast,  260 
Porro's  cesarean  .section,  234 
Pregnancy  complicating  cancer  of  uterus,  201 
Preparation  for  operations,  1 
abdominal  section,  13 
anaesthesia,  19 
hand  cleansing,  19 
of  vagina,  10 
Proctoclysis,  Murphy  drip,  251 
Prolapse  of  uterus,  118 
Pruritis  vulvae,  operation  for,  153 
Pubiotomy,  "246 

advocated  only  for  occasional  operator,  248 

after-treatment  in,  247 

danger  of  compound  fracture  of  pelvis,  248 


INDEX 


291 


Pubiotomy,  inability  to  extract  child  after,  248 
inferiority  of  to  caesarean  section,  246 
morbidity  after,  247 
superiority  of  to  sjinphysiotomy,  246 
technic  of,  247 
treatment  during  convalescence  after,  247 

Rectocele,  operation  for,  30 

Rectovaginal  fistula,  97 

Retractor,  Melpi's,  7 

Retroversion  of  uterus,  operative  treatment  of, 

102 
Reynolds  operation  for  anteflexion  of  uterus, 

118 
Room  for  operations,  1 
Round  ligament,  dissection  of  inguinal  canal 

for  removal  of  fibroid  tumors  of,  153 

S^enger's  conservative  cesarean  section,  225 
Salpingectomy,  158 
drainage  in,  161 
in  ectopic  gestation,  160 
in  gonorrha'al  infection,  160 
operative  procedui-e,  159 
Salpingitis,  acute,  abdominal  drainage  in,  161 
Schauta's  extended  hysterectomy  for  cancer, 

217 
Schede's  operation  for  ureteral  fLstula,  101 
Section,  ca?sarean,  225 
SeUheim  scoop  in  ca?sarean  section,  237 
Shock,  treatment  of,  after  abdominal  section, 

252 
Sigwart  clamp,  S 
Somers'  clamp,  6 

SpinelU  operation  for  inversion  of  uterus,  119 
Sterility,  dilatation  of  cervical  canal  for,  126 
Sterihzing  of  sheets  and  covers,  19 
Supravaginal  amputation  of  uterus  by  abdomi- 
nal section,  184 
extraperitoneal     hysterectomy     by     vaginal 
route,  207 
Suspension  operation  for  retroversion  of  uterus, 

disadvantages  of,  105 
Suture  material  in  abdominal  section,  25 

in  operation  for  complete  tear  of  perineum, 
46 
for  vesicovaginal  fistulae,  94 
on  cervix,  86 
in  perineorrhaphy,  30 
Suturing  after  anterior  vaginal  hysterotomy, 
127 
after  Tliomas-Warren  operation,  264 

Tables  for  operation,  4 
Hirst,  4 


Tables  for  operation,  Loewenstein,  5 
Technic,  operative,  25 
Thomas-Warren  operation,  257,  260 
advantages  of,  261 
dressing  after,  265 

for  exploration  of  mammary  gland,  260 
for  subcutaneous  amputation  of  breast, 

267 
in  suspected  cancer,  265 
inversion  of  n'pple,  correction  of,  dur- 
ing, 264 
suturing  after,  264 
technic,  260 
Thrombosis  of  mesenteric  veins  following  ab- 
dominal section,  252 
Trachelorrhaphy,  Emmet,  in  injuries  of  cervix, 
.  85 

Transposition  operation  (see  Interposition  oper- 
ation), 70 
Tray  and  stand  for  instruments,  5 
Tumor,  fibroid,  hysterectomy  for,  173,  184 
infected,    spraying    uterine    cavity    with 

dichloramin-T  for,  176 
surgical  treatment  of,  173 

myomectomy,  abdominal,  173 
vaginal,  175 
Tumors,  forceps  for  removal  of,  7 
of  breast,  cystic  or  sohd,  excision  of,  257 
closing  the  wound,  257 
Thomas-\\'arren  incision,  257,  260 
possibility  of  lacteal  fistula,  257 
of  malignancj-,  257 
removal  always  advisable,  257 
ovarian  cystic,  removal  of,  169 
Tympanites,     treatment    of,    after   abdominal 
section,  251 
galvanic  current.  252 

I'mbilication  of  nipple,  operative  treatment  for, 

282 
I'reteral  fistulip,  101 
Urogenital  tract,  fistulae  of,  94 

trigonum,  laceration  of  muscle  and  fascia  of. 
55 
ojieration  for,  56 
I'terus,  anteflexion  of,  118 

Dudley  operation  for,  118 
Reynold's  operation  for.  118 
carcinoma  of,  importance  of  early  diagnosis 
and  treatment,  "200 
panhj-sterectomy  for,  197 
pregnancy  complicating,  201 
ill-developed,  electrolysis  for.  128 
inversion  of,  119 
operative  treatment  of,  119 


idi 


INDEX 


I'terus,  operative  treatment  of   inversion   of, 
proper  time  for.  119 
Spinelli  operation,  119 
laceration  or  over-stretching  of  pigments  of, 

causes  of,  55 
prolapse  of,  118 

operative  treatment  of,  118 
retroversion  of,  epilepsy  associated  with,  103 
operative  treatment  of,  102 
Alexander  oi)eration,  104 
causes  of  failure  in,  103 
Coffey  operation,  lOG 
Hirst's  method,  105 
advantages  of,  105 
success  of,  104,  10(j 
relative  advantages  of,  over  pessaries, 

102 
suspension  operation,  105 
sterility  due  to,  103 
symptoms  of,  103 
supravaginal  amputation  of,  by  abdominal 
section,  184 
with  extraperitoneal  fixation  of  cervical 

stump,  234 
with   peritonealization    and   sinking   of 
cervical  stump,  234 
suspension  of,  in  myomectomy,  174 
in  oophorectomy,  170 

Vagina,  artificial,  operations  for,  149 

closure  of,  operation  for,  95 
Vaginal  operations  for  ureteral  fistula,  101 


Vaginal  operations  for  ureteral  fistula,  Bandl's, 
101 
Dudley's,  102 
Mackenrodt's,  102 
Schede's,  101 
preparation  for,  10 
catheterization,  12 
cleaning  the  field  of  operation,  11 
Vaginal  wall,  anterior,  injuries  of,  due  to  labor, 
55 
repair  of,  interposition  operation,  70 
delivery  of  uterus,  70 
separation  of  bladder  and  vag- 
ina, 70 
involving  supports  of  bladder,  55 
Vaginismus,  dilatation  with  Hegar  dilators  for, 
135 
operation  for  enlarging  the  vaginal  introitus 
in,  135 
Vesicovaginal  fistulse,  94 
Vulva,  operations  on,  153 

in  pregnancy,  153 
X'ulvar  nerves,  excision  of,  153 
Vulvovaginal  gland,  removal  of,  154 

Wertheim  clamps,  7 
operation,  197 
clamps  for,  7 
table  for,  5 
panhysterectomy,  197 
Woimds,  abdominal  closure  of,  25 
drainage  after  closure  of,  25 


«, 


Date  Due 

JA^  ; 

Fes  : 

I     1977 

J  AN 

3:,  REC'O 

■ 

(^ 

CAT.    NO.    23 

233                          PRINTED    IN    U.S.A. 

»»'«'^"' 000  630  525  a 


Hirst. 

Atlas  of  operative  gynecology 


WP17 

H669a 

1919 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


